Provider Demographics
NPI:1326248881
Name:BURRELL, RENITA C (DDS)
Entity Type:Individual
Prefix:DR
First Name:RENITA
Middle Name:C
Last Name:BURRELL
Suffix:
Gender:F
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:N68W5460 COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012
Mailing Address - Country:UM
Mailing Address - Phone:262-384-0092
Mailing Address - Fax:
Practice Address - Street 1:2457 N MAYFAIR RD
Practice Address - Street 2:STE 102
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1405
Practice Address - Country:US
Practice Address - Phone:414-257-1221
Practice Address - Fax:414-257-1289
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics