Provider Demographics
NPI:1194929596
Name:DAVID R. BOURQUE, D.D.S. , P.C.
Entity type:Organization
Organization Name:DAVID R. BOURQUE, D.D.S. , P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:BOURQUE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:716-693-1971
Mailing Address - Street 1:3184 WOODLAND CT N
Mailing Address - Street 2:
Mailing Address - City:N TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1153
Mailing Address - Country:US
Mailing Address - Phone:716-693-1971
Mailing Address - Fax:
Practice Address - Street 1:6 DOUBLEDAY COURT
Practice Address - Street 2:NORTHERN CATSKILL DENTAL ASSOCIATES
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1223
Practice Address - Country:US
Practice Address - Phone:607-547-2313
Practice Address - Fax:607-547-6251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY374691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty