Provider Demographics
NPI:1821415563
Name:BURSIAN, JUSTINE (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:BURSIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 SEABOARD LN STE 102
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-3037
Mailing Address - Country:US
Mailing Address - Phone:156-661-0303
Mailing Address - Fax:
Practice Address - Street 1:95 SEABOARD LN STE 102
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-3037
Practice Address - Country:US
Practice Address - Phone:156-661-0303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-19
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN109511223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty