1649583428 NPI number — DR. ELISE BURRUS DDS

Table of content: DR. ELISE BURRUS DDS (NPI 1649583428)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649583428 NPI number — DR. ELISE BURRUS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BURRUS
Provider First Name:
ELISE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649583428
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2379 NW LABICHE LN
Provider Second Line Business Mailing Address:
# 1
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-7178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-280-5186
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
413 NW LARCH AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
REDMOND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97756-1361
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-923-8666
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  6534-015 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: D9707 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)