Provider Demographics
NPI:1235165325
Name:BURKET, BRADLEY JOHN (DMD,MD)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:BURKET
Suffix:
Gender:M
Credentials:DMD,MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 NE PROFESSIONAL CT
Mailing Address - Street 2:STE 1
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6028
Mailing Address - Country:US
Mailing Address - Phone:541-322-9396
Mailing Address - Fax:541-322-9398
Practice Address - Street 1:2195 NE PROFESSIONAL CT
Practice Address - Street 2:STE 1
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6028
Practice Address - Country:US
Practice Address - Phone:541-322-9396
Practice Address - Fax:541-322-9398
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2012-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD66001223G0001X
ORMD19055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1156820001OtherCIGNA
OR002955000OtherBCBS
OR100117OtherCOIHS
OR080507Medicaid
OR7608077OtherAETNA
ORF96227Medicare UPIN
OR0000BLBYFMedicare ID - Type Unspecified