Provider Demographics
NPI:1982633699
Name:BURCHAM DENTAL ARTS CLINIC
Entity Type:Organization
Organization Name:BURCHAM DENTAL ARTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRITT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURCHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-888-3521
Mailing Address - Street 1:205 TEACO RD
Mailing Address - Street 2:P.O. BOX 766
Mailing Address - City:KENNETT
Mailing Address - State:MO
Mailing Address - Zip Code:63857-3236
Mailing Address - Country:US
Mailing Address - Phone:573-888-3521
Mailing Address - Fax:573-888-0973
Practice Address - Street 1:205 TEACO RD
Practice Address - Street 2:
Practice Address - City:KENNETT
Practice Address - State:MO
Practice Address - Zip Code:63857-3236
Practice Address - Country:US
Practice Address - Phone:573-888-3521
Practice Address - Fax:573-888-0973
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0150111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3031860OtherBLUE CROSS BLUE SHIELD
856721OtherUNITED CONCORDIA