Healthcare Provider Details

I. General information

NPI: 1285801324
Provider Name (Legal Business Name): KRISTEN A BURRIS, D.D.S. L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 SOUTH MAIN STREET
SHATTUCK OK
73858
US

IV. Provider business mailing address

PO BOX 609
SHATTUCK OK
73858-0609
US

V. Phone/Fax

Practice location:
  • Phone: 580-938-2566
  • Fax: 580-938-2567
Mailing address:
  • Phone: 580-938-2566
  • Fax: 580-938-2567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4628
License Number StateOK

VIII. Authorized Official

Name: DR. KRISTEN A BURRIS
Title or Position: OWNER
Credential: D.D.S.
Phone: 580-938-2566