Provider Demographics
NPI:1518170976
Name:BURKE, WESLEY J (DDS)
Entity Type:Individual
Prefix:DR
First Name:WESLEY
Middle Name:J
Last Name:BURKE
Suffix:
Gender:M
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:PO BOX 678
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30540-0009
Mailing Address - Country:US
Mailing Address - Phone:706-276-7644
Mailing Address - Fax:
Practice Address - Street 1:160 SAILORS DR
Practice Address - Street 2:
Practice Address - City:ELLIJAY
Practice Address - State:GA
Practice Address - Zip Code:30540-3743
Practice Address - Country:US
Practice Address - Phone:706-276-2828
Practice Address - Fax:706-276-2826
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA79961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA838580OtherUNITED CONCORDIA
GA838580OtherUNITED CONCORDIA