Healthcare Provider Details

I. General information

NPI: 1538268602
Provider Name (Legal Business Name): LEO JOSEPH BURKE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 WEST OSAGE
PACIFIC MO
63069-1332
US

IV. Provider business mailing address

421 WEST 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 Number013246
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: