MEDICARE: DR. IRENE C BOURKE D.M.D.

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	122300000X	Dentist	22DI01541700	NJ

General Provider Information

NPI Number	:	1538355128
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRENE C BOURKE D.M.D.

Provider Business Mailing Address
First Line	:	5 HANNAH RD
Second Line	:
City	:	OAKLAND
State	:	NJ
Zip	:	07436-2513
Country	:	US
Telephone Number	:	201-651-0207
Fax Number	:

Provider Business Practice Location Address
First Line	:	964 FRANKLIN LAKES RD
Second Line	:
City	:	FRANKLIN LAKES
State	:	NJ
Zip	:	07417-2153
Country	:	US
Telephone Number	:	201-891-1171
Fax Number	:

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

Provider Enumeration Date	:	09/18/2007
Last Update Date	:	09/18/2007

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