Provider Demographics
NPI:1467948802
Name:BURCK, MALLORY PAIGE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:PAIGE
Last Name:BURCK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:PAIGE
Other - Last Name:BAUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:2142 LOWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80211-5052
Mailing Address - Country:US
Mailing Address - Phone:682-554-5487
Mailing Address - Fax:
Practice Address - Street 1:3380 W 38TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80211-1910
Practice Address - Country:US
Practice Address - Phone:303-458-1361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00203626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist