Provider Demographics
NPI:1649648858
Name:TERRY A. BURGESS
Entity type:Organization
Organization Name:TERRY A. BURGESS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:256-772-2626
Mailing Address - Street 1:810 PALMER PLAZA
Mailing Address - Street 2:# 103
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758
Mailing Address - Country:US
Mailing Address - Phone:256-772-2626
Mailing Address - Fax:256-772-2602
Practice Address - Street 1:810 PALMER PLAZA
Practice Address - Street 2:# 103
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758
Practice Address - Country:US
Practice Address - Phone:256-772-2626
Practice Address - Fax:256-772-2602
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-09-03
Last Update Date:2016-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4219122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty