Healthcare Provider Details

I. General information

NPI: 1326248881
Provider Name (Legal Business Name): RENITA C BURRELL DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2007
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2457 N MAYFAIR RD STE 102
MILWAUKEE WI
53226-1405
US

IV. Provider business mailing address

N68W5460 COLUMBIA RD
CEDARBURG WI
53012
UM

V. Phone/Fax

Practice location:
  • Phone: 414-257-1221
  • Fax: 414-257-1289
Mailing address:
  • Phone: 262-384-0092
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6086
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: