Provider Demographics
NPI:1134447717
Name:BURGESS-FONGSAM, CAROLE S (DDS)
Entity type:Individual
Prefix:DR
First Name:CAROLE
Middle Name:S
Last Name:BURGESS-FONGSAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17810 MEETING HOUSE RD
Mailing Address - Street 2:MOORE BLDG # 205
Mailing Address - City:SANDY SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20860-1038
Mailing Address - Country:US
Mailing Address - Phone:301-774-3847
Mailing Address - Fax:301-774-4528
Practice Address - Street 1:17810 MEETING HOUSE RD
Practice Address - Street 2:MOORE BLDG # 205
Practice Address - City:SANDY SPRING
Practice Address - State:MD
Practice Address - Zip Code:20860-1038
Practice Address - Country:US
Practice Address - Phone:301-774-3847
Practice Address - Fax:301-774-4528
Is Sole Proprietor?:No
Enumeration Date:2010-05-06
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD96671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice