Provider Demographics
NPI:1407905417
Name:BURK, KELLY M
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:M
Last Name:BURK
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:BURK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:13916 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-5009
Mailing Address - Country:US
Mailing Address - Phone:301-498-6511
Mailing Address - Fax:301-776-0050
Practice Address - Street 1:13916 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-5009
Practice Address - Country:US
Practice Address - Phone:301-498-6511
Practice Address - Fax:301-776-0050
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD115741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice