=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417282450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PORTEOUS & BURKE DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2009
-----------------------------------------------------
Last Update Date | 01/06/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 667 PARKER AVE
-----------------------------------------------------
City | RODEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94572-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-799-4746
-----------------------------------------------------
Fax | 510-799-5475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 667 PARKER AVE
-----------------------------------------------------
City | RODEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94572-1434
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-799-4746
-----------------------------------------------------
Fax | 510-799-5475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR., OWNER
-----------------------------------------------------
Name | DR. PAMELA DANIELLE PORTEOUS-BURKE
-----------------------------------------------------
Credential | DR.
-----------------------------------------------------
Telephone | 510-799-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 56949
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------