MEDICARE: PORTEOUS & BURKE DENTAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	56949	CA

General Provider Information

NPI Number	:	1417282450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PORTEOUS & BURKE DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	667 PARKER AVE
Second Line	:
City	:	RODEO
State	:	CA
Zip	:	94572-1434
Country	:	US
Telephone Number	:	510-799-4746
Fax Number	:	510-799-5475

Provider Business Practice Location Address
First Line	:	667 PARKER AVE
Second Line	:
City	:	RODEO
State	:	CA
Zip	:	94572-1434
Country	:	US
Telephone Number	:	510-799-4746
Fax Number	:	510-799-5475

Authorized Official
Title or Position	:	DR., OWNER
Name	:	DR. PAMELA DANIELLE PORTEOUS-BURKE
Credential	:	DR.
Telephone Number	:	510-799-4746

Provider Enumeration Date	:	10/08/2009
Last Update Date	:	01/06/2011

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