1124408182 NPI number — DR. KELLY FITZGERALD BURNS DMD

Table of content: DR. KELLY FITZGERALD BURNS DMD (NPI 1124408182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124408182 NPI number — DR. KELLY FITZGERALD BURNS DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURNS
Provider First Name:
KELLY
Provider Middle Name:
FITZGERALD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
KELLY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124408182
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
152 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTPELIER
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05602-2913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-229-0690
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
152 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTPELIER
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05602-2913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-229-0690
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/04/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  0160112318 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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