Healthcare Provider Details

I. General information

NPI: 1558928135
Provider Name (Legal Business Name): BURKE FAMILY DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2019
Last Update Date: 06/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200A ROLLING RD
BURKE VA
22015-4696
US

IV. Provider business mailing address

21155 WHITFIELD PLACE SUITE 104
STERLING VA
20165
US

V. Phone/Fax

Practice location:
  • Phone: 703-323-3910
  • Fax:
Mailing address:
  • Phone: 703-433-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JEFFREY PALMER
Title or Position: MANAGER
Credential:
Phone: 703-433-0234