Provider Demographics
NPI:1972729077
Name:BURBACH, DWAYNE ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:ROBERT
Last Name:BURBACH
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 1:7005 ATASCADERO AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-4431
Mailing Address - Country:US
Mailing Address - Phone:805-466-3328
Mailing Address - Fax:805-466-0824
Practice Address - Street 1:7005 ATASCADERO AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-4431
Practice Address - Country:US
Practice Address - Phone:805-466-3328
Practice Address - Fax:805-466-0824
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA288461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA28846OtherSTATE LICENSE NUMBER
CA28846OtherSTATE LICENSE NUMBER