MEDICARE: MR. LEO JOSEPH BURKE DDS

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	1223G0001X	General Practice Dentistry	013246	MO

General Provider Information

NPI Number	:	1538268602
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEO JOSEPH BURKE DDS

Provider Business Mailing Address
First Line	:	421 WEST OSAGE
Second Line	:
City	:	PACIFIC
State	:	MO
Zip	:	63069-1332
Country	:	US
Telephone Number	:	636-257-5515
Fax Number	:	636-257-4433

Provider Business Practice Location Address
First Line	:	421 WEST OSAGE
Second Line	:
City	:	PACIFIC
State	:	MO
Zip	:	63069-1332
Country	:	US
Telephone Number	:	636-257-5515
Fax Number	:	636-257-4433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	07/08/2007

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