MEDICARE: QHSA DBA DR. BRADLEY J BURKET DMD, MD

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	305R00000X	Preferred Provider Organization	MD19055	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538579727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QHSA DBA DR. BRADLEY J BURKET DMD, MD

Provider Business Mailing Address
First Line	:	2195 NE PROFESSIONAL CT STE 1
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-6028
Country	:	US
Telephone Number	:	541-322-9396
Fax Number	:	541-322-9398

Provider Business Practice Location Address
First Line	:	2195 NE PROFESSIONAL CT STE 1
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97701-6028
Country	:	US
Telephone Number	:	541-322-9396
Fax Number	:	541-322-9398

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MISS MISTY BOUGHTON
Credential	:
Telephone Number	:	541-322-0376

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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