Provider Demographics
NPI:1417166000
Name:BURKE, MARY HAGAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:HAGAN
Last Name:BURKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WOODLEIGH CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63122-4805
Mailing Address - Country:US
Mailing Address - Phone:314-821-2588
Mailing Address - Fax:314-821-2903
Practice Address - Street 1:5600 OAKLAND AVE
Practice Address - Street 2:DENTAL HYGIENE ST LOUIS COMMUNITY COLLEGE-FOREST PARK
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1393
Practice Address - Country:US
Practice Address - Phone:314-644-9630
Practice Address - Fax:314-951-9490
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0127061223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics