Provider Demographics
NPI:1649583428
Name:BURRUS, ELISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELISE
Middle Name:
Last Name:BURRUS
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 1:2379 NW LABICHE LN
Mailing Address - Street 2:# 1
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7178
Mailing Address - Country:US
Mailing Address - Phone:541-280-5186
Mailing Address - Fax:
Practice Address - Street 1:413 NW LARCH AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:REDMOND
Practice Address - State:OR
Practice Address - Zip Code:97756-1361
Practice Address - Country:US
Practice Address - Phone:414-923-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6534-0151223P0221X
ORD97071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry