Healthcare Provider Details

I. General information

NPI: 1386743458
Provider Name (Legal Business Name): LEO J BURKE DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 W OSAGE
PACIFIC MO
63069-1332
US

IV. Provider business mailing address

421 W OSAGE
PACIFIC MO
63069-1332
US

V. Phone/Fax

Practice location:
  • Phone: 636-257-5515
  • Fax: 636-257-4433
Mailing address:
  • Phone: 636-257-5515
  • Fax: 636-257-4433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LEO JOSEPH BURKE
Title or Position: PRESIDENT
Credential: DDS
Phone: 636-257-5515