Provider Demographics
NPI:1104941541
Name:BURLESON, JERRY W (DDS)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:W
Last Name:BURLESON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:OH
Mailing Address - Zip Code:45662-3606
Mailing Address - Country:US
Mailing Address - Phone:740-354-3395
Mailing Address - Fax:740-353-8405
Practice Address - Street 1:1500 GRANT ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-3606
Practice Address - Country:US
Practice Address - Phone:740-354-3395
Practice Address - Fax:740-353-8405
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH15628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0355511Medicaid