Provider Demographics
NPI:1700835840
Name:BURKE, EDWINA L (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWINA
Middle Name:L
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 1:755 BOARDMAN-CANFIELD ROAD UNIT L2
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512
Mailing Address - Country:US
Mailing Address - Phone:330-758-8979
Mailing Address - Fax:330-758-8296
Practice Address - Street 1:755 BOARDMAN-CANFIELD ROAD UNIT L2
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512
Practice Address - Country:US
Practice Address - Phone:330-758-8979
Practice Address - Fax:330-758-8296
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-08
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH019843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0993199Medicaid