Healthcare Provider Details

I. General information

NPI: 1003912874
Provider Name (Legal Business Name): AMY ELLIS BURLESON D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 GILLHAM RD
KANSAS CITY MO
64108-4619
US

IV. Provider business mailing address

2401 GILLHAM ROAD PROVIDER ENROLLMENT DEPARTMENT
KANSAS CITY MO
64108-4619
US

V. Phone/Fax

Practice location:
  • Phone: 816-234-3257
  • Fax:
Mailing address:
  • Phone: 816-701-5200
  • Fax: 816-302-9939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2002013150
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: