Provider Demographics
NPI:1104999531
Name:BURGESS, BRIAN WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:WAYNE
Last Name:BURGESS
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 1:2831 TIERRA DR
Mailing Address - Street 2:#309
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-5003
Mailing Address - Country:US
Mailing Address - Phone:402-423-3688
Mailing Address - Fax:
Practice Address - Street 1:3800 OLD CHENEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-5901
Practice Address - Country:US
Practice Address - Phone:402-423-3260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47071760200Medicaid
NE47071760200Medicaid
NE260759Medicare ID - Type Unspecified