Provider Demographics
NPI:1528565009
Name:BURKE DENTAL, PLLC
Entity Type:Organization
Organization Name:BURKE DENTAL, PLLC
Other - Org Name:STAG DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID ERIK
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, GPR
Authorized Official - Phone:231-642-2042
Mailing Address - Street 1:PO BOX 518
Mailing Address - Street 2:
Mailing Address - City:KINGSLEY
Mailing Address - State:MI
Mailing Address - Zip Code:49649-0518
Mailing Address - Country:US
Mailing Address - Phone:231-642-2042
Mailing Address - Fax:
Practice Address - Street 1:116 W MAIN ST
Practice Address - Street 2:
Practice Address - City:KINGSLEY
Practice Address - State:MI
Practice Address - Zip Code:49649-5109
Practice Address - Country:US
Practice Address - Phone:231-642-2042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-10
Last Update Date:2020-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI802133003261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental