Provider Demographics
NPI:1417570250
Name:BURGOS, JULISSA E (DMD)
Entity type:Individual
Prefix:DR
First Name:JULISSA
Middle Name:E
Last Name:BURGOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10510 RIDGE COVE LN
Mailing Address - Street 2:
Mailing Address - City:SPOTSYLVANIA
Mailing Address - State:VA
Mailing Address - Zip Code:22551-4720
Mailing Address - Country:US
Mailing Address - Phone:561-806-9766
Mailing Address - Fax:
Practice Address - Street 1:963 GARRISONVILLE RD STE 103
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-3914
Practice Address - Country:US
Practice Address - Phone:540-699-2441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014178661223G0001X
OH30.026216122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Yes1223G0001XDental ProvidersDentistGeneral Practice