1538579727 NPI number — QHSA DBA DR. BRADLEY J BURKET DMD, MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538579727 NPI number — QHSA DBA DR. BRADLEY J BURKET DMD, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
QHSA DBA DR. BRADLEY J BURKET DMD, MD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538579727
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/28/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2195 NE PROFESSIONAL CT STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97701-6028
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-322-9396
Provider Business Mailing Address Fax Number:
541-322-9398

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2195 NE PROFESSIONAL CT STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97701-6028
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-322-9396
Provider Business Practice Location Address Fax Number:
541-322-9398
Provider Enumeration Date:
04/28/2014

Additional Information

Authorized Official

Authorized Official Last Name:
BOUGHTON
Authorized Official First Name:
MISTY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
541-322-0376

Provider Taxonomy Codes

  • Taxonomy code: 305R00000X , with the licence number:  MD19055 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000BLBYF , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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