Provider Demographics
NPI:1124189980
Name:BURDO, GREGORY (DMD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:BURDO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10108 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3704
Mailing Address - Country:US
Mailing Address - Phone:215-677-3904
Mailing Address - Fax:215-354-9125
Practice Address - Street 1:3 AINSLEY CT
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-4230
Practice Address - Country:US
Practice Address - Phone:215-497-8339
Practice Address - Fax:215-513-7192
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0360981223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101703527Medicaid
PA101703527Medicare ID - Type Unspecified