Provider Demographics
NPI:1710879697
Name:ST. CLAIR ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity type:Organization
Organization Name:ST. CLAIR ORAL AND MAXILLOFACIAL SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BOURNIAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:586-727-6800
Mailing Address - Street 1:70 S DEEPLANDS RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-2642
Mailing Address - Country:US
Mailing Address - Phone:248-882-3195
Mailing Address - Fax:
Practice Address - Street 1:36610 HERITAGE DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:MI
Practice Address - Zip Code:48062-1937
Practice Address - Country:US
Practice Address - Phone:586-727-6880
Practice Address - Fax:586-727-6880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery