Provider Demographics
NPI:1417485954
Name:LYSNE-BURSON, DESSEREE MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:DESSEREE
Middle Name:MARIE
Last Name:LYSNE-BURSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:DESSEREE
Other - Middle Name:MARIE
Other - Last Name:LYSNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:3655 E GRANT RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-2933
Mailing Address - Country:US
Mailing Address - Phone:520-670-3909
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:3655 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85716-2933
Practice Address - Country:US
Practice Address - Phone:520-670-3909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009736122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ301783Medicaid