Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 2002013150 | MO |
NPI | 1003912874 |
---|---|
Provider Name | Dr. Amy Ellis Burleson |
First Address | Kansas City, MO 64108-3226 |
Second Address | Kansas City, MO 64108-4619 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
U96453 | (02) | MO |