Provider Demographics
NPI:1659426930
Name:BURWINKEL FAMILY DENTRISTRY
Entity Type:Organization
Organization Name:BURWINKEL FAMILY DENTRISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BURWINKEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-393-1634
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45133-0190
Mailing Address - Country:US
Mailing Address - Phone:937-393-1634
Mailing Address - Fax:937-393-8509
Practice Address - Street 1:323 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-1173
Practice Address - Country:US
Practice Address - Phone:937-393-1634
Practice Address - Fax:937-393-8509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300184901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0197497Medicaid