Basic Information
| Provider Information | |||||||||
| NPI: | 1346567112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURBANK | ||||||||
| FirstName: | JAROM | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 652 HAMILTON RD | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | 5804424002 | ||||||||
| Practice Location | |||||||||
| Address1: | 652 HAMILTON RD | ||||||||
| Address2: | USA DENTAL ACTIVITY | ||||||||
| City: | FORT SILL | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5804423905 | ||||||||
| FaxNumber: | 5804424002 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 07/21/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 7485620-9921 | UT | Y | Dental Providers | Dentist |
No ID Information.