Healthcare Provider Details

I. General information

NPI: 1124189980
Provider Name (Legal Business Name): GREGORY BURDO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 AINSLEY CT
NEWTOWN PA
18940-4230
US

IV. Provider business mailing address

10108 BUSTLETON AVE
PHILADELPHIA PA
19116-3704
US

V. Phone/Fax

Practice location:
  • Phone: 215-497-8339
  • Fax: 215-513-7192
Mailing address:
  • Phone: 215-677-3904
  • Fax: 215-354-9125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDS036098
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: