Basic Information
| Provider Information | |||||||||
| NPI: | 1538579727 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | QHSA DBA DR. BRADLEY J BURKET DMD, MD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DR. BRALDEY J BURKET DMD, MD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2195 NE PROFESSIONAL CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413229396 | ||||||||
| FaxNumber: | 5413229398 | ||||||||
| Practice Location | |||||||||
| Address1: | 2195 NE PROFESSIONAL CT STE 1 | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413229396 | ||||||||
| FaxNumber: | 5413229398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOUGHTON | ||||||||
| AuthorizedOfficialFirstName: | MISTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5413220376 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | MD19055 | OR | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 000BLBYF | 05 | OR | MEDICAID |