Provider Demographics
NPI:1811073208
Name:BURRIS, KRISTEN A (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:A
Last Name:BURRIS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-0609
Mailing Address - Country:US
Mailing Address - Phone:580-938-2566
Mailing Address - Fax:580-938-2567
Practice Address - Street 1:1515 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858
Practice Address - Country:US
Practice Address - Phone:580-938-2566
Practice Address - Fax:580-938-2567
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090140AMedicaid