Provider Demographics
NPI:1588838197
Name:BURKE DENTAL CENTER PC
Entity Type:Organization
Organization Name:BURKE DENTAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:PELLERIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-554-7044
Mailing Address - Street 1:213 COUNCIL ST
Mailing Address - Street 2:P O BOX 360
Mailing Address - City:WAYNESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30830-1453
Mailing Address - Country:US
Mailing Address - Phone:706-554-7044
Mailing Address - Fax:706-554-7045
Practice Address - Street 1:213 COUNCIL ST
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:GA
Practice Address - Zip Code:30830-1453
Practice Address - Country:US
Practice Address - Phone:706-554-7044
Practice Address - Fax:706-554-7045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty