Provider Demographics
NPI:1225033475
Name:BURSON, STACEE (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:STACEE
Middle Name:
Last Name:BURSON
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5508 COWHORN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-9101
Mailing Address - Country:US
Mailing Address - Phone:903-334-8080
Mailing Address - Fax:
Practice Address - Street 1:5508 COWHORN CREEK RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-9101
Practice Address - Country:US
Practice Address - Phone:903-334-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX175371223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics