Provider Demographics
NPI:1639392301
Name:BURKE, ANGELA G (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:G
Last Name:BURKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1471 CHESTER BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1946
Mailing Address - Country:US
Mailing Address - Phone:765-962-4774
Mailing Address - Fax:765-962-4774
Practice Address - Street 1:1471 CHESTER BLVD STE B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1946
Practice Address - Country:US
Practice Address - Phone:765-962-4774
Practice Address - Fax:765-962-4774
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2020-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200124280AMedicaid