Healthcare Provider Details

I. General information

NPI: 1740662709
Provider Name (Legal Business Name): BRIDGET R. BURRIS D. D. S., P. C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 S TRIVIZ DR
LAS CRUCES NM
88001-5103
US

IV. Provider business mailing address

1748 S TRIVIZ DR
LAS CRUCES NM
88001-5103
US

V. Phone/Fax

Practice location:
  • Phone: 575-522-1983
  • Fax: 575-522-3435
Mailing address:
  • Phone: 575-522-1983
  • Fax: 575-522-3435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number1551
License Number StateNM

VIII. Authorized Official

Name: DR. BRIDGET R. BURRIS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 575-522-1983