Provider Demographics
NPI:1073824223
Name:BURLINGAME, MICHELLE L (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:L
Last Name:BURLINGAME
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:L
Other - Last Name:STANISLOWSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:220 CHURCH AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3613
Mailing Address - Country:US
Mailing Address - Phone:518-885-9473
Mailing Address - Fax:518-885-1212
Practice Address - Street 1:220 CHURCH AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:BALLSTON SPA
Practice Address - State:NY
Practice Address - Zip Code:12020-3613
Practice Address - Country:US
Practice Address - Phone:518-248-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054888-11223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics