Basic Information
| Provider Information | |||||||||
| NPI: | 1447430178 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURKE | ||||||||
| FirstName: | VERNON | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10175 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155046880 | ||||||||
| FaxNumber: | 9155998579 | ||||||||
| Practice Location | |||||||||
| Address1: | 10175 GATEWAY BLVD W | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799257618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155046880 | ||||||||
| FaxNumber: | 9155998579 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2007 | ||||||||
| LastUpdateDate: | 03/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223S0112X | 25153 | TX | Y | Dental Providers | Dentist | Oral and Maxillofacial Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1447430178 | 05 | TX | MEDICAID |