Basic Information
Provider Information | |||||||||
NPI: | 1235165325 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BURKET | ||||||||
FirstName: | BRADLEY | ||||||||
MiddleName: | JOHN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.M.D.,M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2195 NE PROFESSIONAL CT | ||||||||
Address2: | STE 1 | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413229396 | ||||||||
FaxNumber: | 5413229398 | ||||||||
Practice Location | |||||||||
Address1: | 2195 NE PROFESSIONAL CT | ||||||||
Address2: | STE 1 | ||||||||
City: | BEND | ||||||||
State: | OR | ||||||||
PostalCode: | 977016028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5413229396 | ||||||||
FaxNumber: | 5413229398 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2006 | ||||||||
LastUpdateDate: | 01/17/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D6600 | OR | N |   | Dental Providers | Dentist | General Practice | 207Q00000X | MD19055 | OR | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 1156820001 | 01 | OR | CIGNA | OTHER | 002955000 | 01 | OR | BCBS | OTHER | 100117 | 01 | OR | COIHS | OTHER | 080507 | 05 | OR |   | MEDICAID | 7608077 | 01 | OR | AETNA | OTHER |