Healthcare Provider Details

I. General information

NPI: 1417843426
Provider Name (Legal Business Name): ELLIE NICOLE PETERSEN-BURKLE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 DODGE ST
OMAHA NE
68114-4113
US

IV. Provider business mailing address

19467 U ST
OMAHA NE
68135-4210
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-6100
  • Fax:
Mailing address:
  • Phone: 402-429-4016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8098
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: