Healthcare Provider Details

I. General information

NPI: 1275376907
Provider Name (Legal Business Name): DANIEL L BUERK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 06/18/2024
Certification Date: 06/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 E CENTRAL DR
MERIDIAN ID
83642-7991
US

IV. Provider business mailing address

749 E PARK BLVD
BOISE ID
83712-7794
US

V. Phone/Fax

Practice location:
  • Phone: 208-373-1860
  • Fax:
Mailing address:
  • Phone: 618-660-8669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-5646
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: