Provider Demographics
NPI:1114234556
Name:ULTRA ORTHODONTICS
Entity Type:Organization
Organization Name:ULTRA ORTHODONTICS
Other - Org Name:BURSON ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:903-261-4711
Mailing Address - Street 1:627 TURTLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-1832
Mailing Address - Country:US
Mailing Address - Phone:903-597-6372
Mailing Address - Fax:903-592-8482
Practice Address - Street 1:3006 H G MOSLEY PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-2948
Practice Address - Country:US
Practice Address - Phone:903-753-2151
Practice Address - Fax:903-753-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty