MEDICARE: BURLEIGH DENTAL, SC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	2503	WI

General Provider Information

NPI Number	:	1437152493
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BURLEIGH DENTAL, SC

Provider Business Mailing Address
First Line	:	7623 W BURLEIGH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-5001
Country	:	US
Telephone Number	:	414-444-4334
Fax Number	:	414-444-3222

Provider Business Practice Location Address
First Line	:	7623 W BURLEIGH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-5001
Country	:	US
Telephone Number	:	414-444-4334
Fax Number	:	414-444-3222

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL DONOHOO
Credential	:	DDS
Telephone Number	:	414-444-4334

Provider Enumeration Date	:	05/24/2005
Last Update Date	:	09/10/2008

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