Provider Demographics
NPI:1679619373
Name:BURLESON, BRIAN KEITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:BURLESON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 N FEDERAL AVE
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-3214
Mailing Address - Country:US
Mailing Address - Phone:641-450-0601
Mailing Address - Fax:641-450-0612
Practice Address - Street 1:404 N FEDERAL AVE
Practice Address - Street 2:
Practice Address - City:MASON CITY
Practice Address - State:IA
Practice Address - Zip Code:50401
Practice Address - Country:US
Practice Address - Phone:641-450-0601
Practice Address - Fax:641-450-0612
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209401223G0001X
IA090651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice