Provider Demographics
NPI:1336824796
Name:BURSIAN ORTIZ, MONICA MICHELLE (DMD)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:MICHELLE
Last Name:BURSIAN ORTIZ
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11829 DUXBURY DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-1848
Mailing Address - Country:US
Mailing Address - Phone:321-749-5758
Mailing Address - Fax:
Practice Address - Street 1:7200 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4205
Practice Address - Country:US
Practice Address - Phone:972-632-3317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2025-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN28074122300000X
TX408631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist