Provider Demographics
NPI:1417843426
Name:PETERSEN-BURKLE, ELLIE NICOLE (DDS)
Entity type:Individual
Prefix:
First Name:ELLIE
Middle Name:NICOLE
Last Name:PETERSEN-BURKLE
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 1:19467 U ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68135-4210
Mailing Address - Country:US
Mailing Address - Phone:402-429-4016
Mailing Address - Fax:
Practice Address - Street 1:8200 DODGE ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4113
Practice Address - Country:US
Practice Address - Phone:402-559-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE8098122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist