Basic Information
Provider Information
NPI: 1033559760
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BURKS
FirstName: WILLIAM
MiddleName: H.
NamePrefix: DR.
NameSuffix: III
Credential: DDS
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1326 S MAIN ST
Address2:  
City: OTTAWA
State: KS
PostalCode: 660673527
CountryCode: US
TelephoneNumber: 7852424875
FaxNumber: 7852425325
Practice Location
Address1: 1326 S MAIN ST
Address2:  
City: OTTAWA
State: KS
PostalCode: 660673527
CountryCode: US
TelephoneNumber: 7852424875
FaxNumber: 7852425325
Other Information
ProviderEnumerationDate: 06/26/2013
LastUpdateDate: 06/26/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X5996KSY Dental ProvidersDentist 

ID Information
IDTypeStateIssuerDescription
821301KSBLUE CROSS BLUE SHIELDOTHER
69873801 TRICAREOTHER
1238101101 BLUE CROSS BLUE SHIELD OF KANSAS CITYOTHER


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