Provider Demographics
NPI:1730499757
Name:BURSON, KENNETH MICHAEL (MS, DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:MICHAEL
Last Name:BURSON
Suffix:
Gender:M
Credentials:MS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 E 17TH AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-1126
Mailing Address - Country:US
Mailing Address - Phone:303-731-2005
Mailing Address - Fax:
Practice Address - Street 1:2190 E 17TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206
Practice Address - Country:US
Practice Address - Phone:303-731-2005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN10283122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000153400Medicaid