Provider Demographics
NPI:1588077598
Name:NATHAN BOURASSA DDS PA
Entity type:Organization
Organization Name:NATHAN BOURASSA DDS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:BOURASSA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-664-9506
Mailing Address - Street 1:509 W HANLEY AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8994
Mailing Address - Country:US
Mailing Address - Phone:208-664-9506
Mailing Address - Fax:208-665-1598
Practice Address - Street 1:509 W HANLEY AVE STE 102
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8994
Practice Address - Country:US
Practice Address - Phone:208-664-9506
Practice Address - Fax:208-665-1598
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty