Healthcare Provider Details

I. General information

NPI: 1811073208
Provider Name (Legal Business Name): KRISTEN A BURRIS D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
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:
Title or Position:
Credential:
Phone: