Provider Demographics
NPI:1902012602
Name:BURNS, GREGORY DEWAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:DEWAYNE
Last Name:BURNS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2010 E. 70TH ST.
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105
Mailing Address - Country:US
Mailing Address - Phone:318-798-3000
Mailing Address - Fax:318-798-3044
Practice Address - Street 1:2010 E. 70TH ST.
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105
Practice Address - Country:US
Practice Address - Phone:318-798-3000
Practice Address - Fax:318-798-3044
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA57871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1857874Medicaid