Provider Demographics
NPI:1952431546
Name:BURGESS, JEFFREY A (DDS MSD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:A
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DDS MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 NE 63RD ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6930
Mailing Address - Country:US
Mailing Address - Phone:800-515-0018
Mailing Address - Fax:
Practice Address - Street 1:735 BISHOP ST
Practice Address - Street 2:SUITE 333
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-4817
Practice Address - Country:US
Practice Address - Phone:800-515-0018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI9051223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIT01994Medicare UPIN
HI100193Medicare PIN