Provider Demographics
NPI:1871863431
Name:BURLESON ORTHODONTICS AND PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:BURLESON ORTHODONTICS AND PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BURLESON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:816-318-8820
Mailing Address - Street 1:401 LAURUS DR
Mailing Address - Street 2:
Mailing Address - City:RAYMORE
Mailing Address - State:MO
Mailing Address - Zip Code:64083
Mailing Address - Country:US
Mailing Address - Phone:816-318-8820
Mailing Address - Fax:
Practice Address - Street 1:401 LAURUS DR
Practice Address - Street 2:
Practice Address - City:RAYMORE
Practice Address - State:MO
Practice Address - Zip Code:64083
Practice Address - Country:US
Practice Address - Phone:816-318-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020131501223P0221X
MO20040132431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty