Provider Demographics
NPI:1417485954
Name:LYSNE-BURSON, DESSEREE MARIE (DMD)
Entity type:Individual
Prefix:DR
First Name:DESSEREE
Middle Name:MARIE
Last Name:LYSNE-BURSON
Suffix:
Gender:
Credentials:DMD
Other - Prefix:MISS
Other - First Name:DESSEREE
Other - Middle Name:MARIE
Other - Last Name:LYSNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS
Mailing Address - Street 1:2816 39 1/2 AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7014
Mailing Address - Country:US
Mailing Address - Phone:025-098-1326
Mailing Address - Fax:
Practice Address - Street 1:2101 ELM ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-2417
Practice Address - Country:US
Practice Address - Phone:701-232-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-29
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0097361223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ301783Medicaid