Provider Demographics
NPI:1285869792
Name:BURK, THERON REED (DMD)
Entity type:Individual
Prefix:DR
First Name:THERON
Middle Name:REED
Last Name:BURK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 COORS BLVD NW STE D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1405
Mailing Address - Country:US
Mailing Address - Phone:505-344-6565
Mailing Address - Fax:505-344-8217
Practice Address - Street 1:6588 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5122
Practice Address - Country:US
Practice Address - Phone:505-326-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD31241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice