Healthcare Provider Details

I. General information

NPI: 1285869792
Provider Name (Legal Business Name): THERON REED BURK DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6588 E MAIN ST
FARMINGTON NM
87402-5122
US

IV. Provider business mailing address

3700 COORS BLVD NW STE D
ALBUQUERQUE NM
87120-1405
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-6800
  • Fax:
Mailing address:
  • Phone: 505-344-6565
  • Fax: 505-344-8217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD3124
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: