Provider Demographics
NPI:1912074410
Name:BURKHOLDER, DONALD M (DDS)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:M
Last Name:BURKHOLDER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 MENTOR AVE
Mailing Address - Street 2:
Mailing Address - City:PAINESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44077
Mailing Address - Country:US
Mailing Address - Phone:440-354-2183
Mailing Address - Fax:440-354-0811
Practice Address - Street 1:78 N CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:OH
Practice Address - Zip Code:44047
Practice Address - Country:US
Practice Address - Phone:440-576-7040
Practice Address - Fax:440-576-0022
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH134441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0176581Medicaid