Provider Demographics
NPI:1194066860
Name:BURRIS, III, CLYDE WALCEY III (DDS)
Entity type:Individual
Prefix:MR
First Name:CLYDE
Middle Name:WALCEY
Last Name:BURRIS, III
Suffix:III
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:PO BOX 483
Mailing Address - Street 2:
Mailing Address - City:RIDGEWAY
Mailing Address - State:VA
Mailing Address - Zip Code:24148-0483
Mailing Address - Country:US
Mailing Address - Phone:276-956-9000
Mailing Address - Fax:276-956-9002
Practice Address - Street 1:4950 GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:RIDGEWAY
Practice Address - State:VA
Practice Address - Zip Code:24148-3390
Practice Address - Country:US
Practice Address - Phone:276-956-9000
Practice Address - Fax:276-956-9002
Is Sole Proprietor?:No
Enumeration Date:2013-03-06
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010086491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice