Healthcare Provider Details

I. General information

NPI: 1376598722
Provider Name (Legal Business Name): DENNIS BRENT BURKETT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4404 RED TAIL CT NW
ALBUQUERQUE NM
87114-4129
US

IV. Provider business mailing address

4404 RED TAIL CT NW
ALBUQUERQUE NM
87114-4129
US

V. Phone/Fax

Practice location:
  • Phone: 505-899-1179
  • Fax:
Mailing address:
  • Phone: 505-899-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number88-132
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: