Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 7404 | MN |
NPI | 1003907122 |
---|---|
Provider Name | Douglas Wilford Burgess |
First Address | Mankato, MN 56001 |
Second Address | Mankato, MN 56001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/09/2006 |
Last Update Date | 08/07/2007 |