Basic Information
| Provider Information | |||||||||
| NPI: | 1295839207 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1200 UNIVERSITY AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | DES MOINES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 503142355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152481447 | ||||||||
| FaxNumber: | 5152481440 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 E LINN ST | ||||||||
| Address2: | |||||||||
| City: | MARSHALLTOWN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418446230 | ||||||||
| FaxNumber: | 6418446235 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2006 | ||||||||
| LastUpdateDate: | 07/31/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 08579 | IA | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 1197186 | 05 | IA | MEDICAID |