Provider Demographics
NPI:1558187062
Name:BURGOS, KEVIN A
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:BURGOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-8603
Mailing Address - Country:US
Mailing Address - Phone:973-800-7924
Mailing Address - Fax:
Practice Address - Street 1:272 US HIGHWAY 46
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-2405
Practice Address - Country:US
Practice Address - Phone:862-640-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22HI01278400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist