Provider Demographics
NPI:1508130865
Name:BURKE, JEFFRY ADAM (DMD)
Entity Type:Individual
Prefix:
First Name:JEFFRY
Middle Name:ADAM
Last Name:BURKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 204
Mailing Address - Street 2:
Mailing Address - City:DALEVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24083-0204
Mailing Address - Country:US
Mailing Address - Phone:864-903-9731
Mailing Address - Fax:
Practice Address - Street 1:24 TINKER MILL RD
Practice Address - Street 2:
Practice Address - City:DALEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24083-3716
Practice Address - Country:US
Practice Address - Phone:540-992-1020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDGD.8084GD122300000X
VA0401415562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist