Provider Demographics
NPI:1558371633
Name:BURKE, BRIAN OSCAR (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:OSCAR
Last Name:BURKE
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10409 MIDLOTHIAN TPKE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4407
Mailing Address - Country:US
Mailing Address - Phone:804-562-2667
Mailing Address - Fax:804-562-2698
Practice Address - Street 1:10409 MIDLOTHIAN TPKE
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4407
Practice Address - Country:US
Practice Address - Phone:804-562-2667
Practice Address - Fax:804-562-2698
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN012570122300000X
OK6340122300000X
IN12011228A122300000X
VA390200000X
VA04014135751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA415429674AMedicaid