Healthcare Provider Details

I. General information

NPI: 1043457476
Provider Name (Legal Business Name): PETTY, BIELIK & BURKE ORTHODONTICS, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2009
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10343 W LINCOLN HWY
FRANKFORT IL
60423-1280
US

IV. Provider business mailing address

10343 W LINCOLN HWY
FRANKFORT IL
60423-1280
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-7150
  • Fax: 815-469-7152
Mailing address:
  • Phone: 815-469-7150
  • Fax: 815-469-7152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number021001977
License Number StateIL

VIII. Authorized Official

Name: DR. JOHN C. BURKE
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 815-469-7150