Provider Demographics
NPI:1598040263
Name:RENITA C BURRELL, DDS, MS, S.C.
Entity Type:Organization
Organization Name:RENITA C BURRELL, DDS, MS, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RENITA
Authorized Official - Middle Name:C
Authorized Official - Last Name:BURRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:262-384-0092
Mailing Address - Street 1:2457 N MAYFAIR RD STE 102
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-1405
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2457 N MAYFAIR RD STE 102
Practice Address - Street 2:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-13
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6086-15261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental