Provider Demographics
NPI:1033322508
Name:BURSICK, BRIAN BRADLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:BRADLEY
Last Name:BURSICK
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 1:5510 LORRAINE AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106
Mailing Address - Country:US
Mailing Address - Phone:712-274-8708
Mailing Address - Fax:
Practice Address - Street 1:4100 MORNINGSIDE AVENUE
Practice Address - Street 2:SUITE B
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106
Practice Address - Country:US
Practice Address - Phone:712-274-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA77461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice