Provider Demographics
NPI:1942302294
Name:BURRIS, BENJAMIN GRAY (DDS, MDS)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:GRAY
Last Name:BURRIS
Suffix:
Gender:M
Credentials:DDS, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:837 GOOD HOMES ROAD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818
Mailing Address - Country:US
Mailing Address - Phone:870-926-5321
Mailing Address - Fax:
Practice Address - Street 1:837 GOOD HOMES ROAD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32818
Practice Address - Country:US
Practice Address - Phone:870-926-5321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-05
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS3-222C122300000X
AR3465122300000X
CA101237122300000X
IL109030995122300000X
KY9869122300000X
LA6020122300000X
MO2009033293122300000X
OK200122300000X
NY58955122300000X
TN9071122300000X
TX25757122300000X
UT10186273-9921122300000X
AR1041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist