Provider Demographics
NPI:1184938243
Name:BURKE ORTHODONTICS, PLLC
Entity type:Organization
Organization Name:BURKE ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:GLEN
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:435-632-9742
Mailing Address - Street 1:817 W WILTSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-8552
Mailing Address - Country:US
Mailing Address - Phone:435-632-9742
Mailing Address - Fax:
Practice Address - Street 1:817 W WILTSHIRE ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:UT
Practice Address - Zip Code:84780-8552
Practice Address - Country:US
Practice Address - Phone:435-632-9742
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-31
Last Update Date:2010-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7598338-99211223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty