Provider Demographics
NPI:1417282450
Name:PORTEOUS & BURKE DENTAL CORPORATION
Entity Type:Organization
Organization Name:PORTEOUS & BURKE DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR., OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:DANIELLE
Authorized Official - Last Name:PORTEOUS-BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:510-799-4746
Mailing Address - Street 1:667 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:RODEO
Mailing Address - State:CA
Mailing Address - Zip Code:94572-1434
Mailing Address - Country:US
Mailing Address - Phone:510-799-4746
Mailing Address - Fax:510-799-5475
Practice Address - Street 1:667 PARKER AVE
Practice Address - Street 2:
Practice Address - City:RODEO
Practice Address - State:CA
Practice Address - Zip Code:94572-1434
Practice Address - Country:US
Practice Address - Phone:510-799-4746
Practice Address - Fax:510-799-5475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-08
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56949122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty