Provider Demographics
NPI:1710355680
Name:BUREK, CARLY (MCN, RDN, LD)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BUREK
Suffix:
Gender:F
Credentials:MCN, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5445 LA SIERRA DR
Mailing Address - Street 2:200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4139
Mailing Address - Country:US
Mailing Address - Phone:214-706-0619
Mailing Address - Fax:
Practice Address - Street 1:5445 LA SIERRA DR
Practice Address - Street 2:200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4139
Practice Address - Country:US
Practice Address - Phone:214-706-0619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83562133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered