Provider Demographics
NPI:1649763194
Name:BURKERT, ELYSE NICOLE (DDS)
Entity Type:Individual
Prefix:
First Name:ELYSE
Middle Name:NICOLE
Last Name:BURKERT
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 1:401 ARBORCREST DR
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2607
Mailing Address - Country:US
Mailing Address - Phone:972-841-8043
Mailing Address - Fax:
Practice Address - Street 1:2268 N LAKE SHORE DR STE 104
Practice Address - Street 2:
Practice Address - City:ROCKWALL
Practice Address - State:TX
Practice Address - Zip Code:75087-0280
Practice Address - Country:US
Practice Address - Phone:469-616-0507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-10
Last Update Date:2018-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX341731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice