Provider Demographics
NPI:1073998480
Name:JAMES BOURNE DDS PC
Entity type:Organization
Organization Name:JAMES BOURNE DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:RANDALL
Authorized Official - Last Name:BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-235-8574
Mailing Address - Street 1:3732 BEN WALTERS LN
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603-7704
Mailing Address - Country:US
Mailing Address - Phone:907-235-8574
Mailing Address - Fax:907-235-7593
Practice Address - Street 1:3732 BEN WALTERS LN
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603-7704
Practice Address - Country:US
Practice Address - Phone:907-235-8574
Practice Address - Fax:907-235-7593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKAK1516122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1598094Medicaid