Provider Demographics
NPI:1265924096
Name:BURGOS, KARISSA (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:KARISSA
Middle Name:
Last Name:BURGOS
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 ANTON WAY
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91784-1508
Mailing Address - Country:US
Mailing Address - Phone:909-967-8553
Mailing Address - Fax:
Practice Address - Street 1:382 W LAKE MEAD PKWY STE 130
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89015-7292
Practice Address - Country:US
Practice Address - Phone:702-558-8543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1060731223X0400X
NVS3-393C1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics