Provider Demographics
NPI:1699332445
Name:BURSCH, ELLEN (DDS)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:BURSCH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 23RD AVE E
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-3707
Mailing Address - Country:US
Mailing Address - Phone:715-398-3239
Mailing Address - Fax:
Practice Address - Street 1:418 23RD AVE E
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:WI
Practice Address - Zip Code:54880-3707
Practice Address - Country:US
Practice Address - Phone:715-398-3239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND14221122300000X
WI600124215122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist