Provider Demographics
NPI:1285801324
Name:KRISTEN A BURRIS, D.D.S. L.L.C.
Entity type:Organization
Organization Name:KRISTEN A BURRIS, D.D.S. L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BURRIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:580-938-2566
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:SHATTUCK
Mailing Address - State:OK
Mailing Address - Zip Code:73858-0609
Mailing Address - Country:US
Mailing Address - Phone:580-938-2566
Mailing Address - Fax:580-938-2567
Practice Address - Street 1:1515 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHATTUCK
Practice Address - State:OK
Practice Address - Zip Code:73858
Practice Address - Country:US
Practice Address - Phone:580-938-2566
Practice Address - Fax:580-938-2567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-08
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK46281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100090140AMedicaid