Provider Demographics
NPI:1861563041
Name:LARRY D. BURNSIDE D.D.S.,P.A.
Entity type:Organization
Organization Name:LARRY D. BURNSIDE D.D.S.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:BURNSIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:904-268-0904
Mailing Address - Street 1:711 CREIGHTON RD
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32003-7008
Mailing Address - Country:US
Mailing Address - Phone:904-264-2759
Mailing Address - Fax:904-268-0306
Practice Address - Street 1:12708 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2689
Practice Address - Country:US
Practice Address - Phone:904-268-0904
Practice Address - Fax:904-268-0306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL7825122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty