Provider Demographics
NPI:1376598722
Name:BURKETT, DENNIS BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:BRENT
Last Name:BURKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4404 RED TAIL CT NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4129
Mailing Address - Country:US
Mailing Address - Phone:505-899-1179
Mailing Address - Fax:
Practice Address - Street 1:4404 RED TAIL CT NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87114-4129
Practice Address - Country:US
Practice Address - Phone:505-899-1179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM88-132207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMA028OtherTRICARE
NME51949Medicare UPIN