Provider Demographics
NPI:1093836017
Name:BOURCIER, MARK A (DMD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BOURCIER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:391 MONTGOMERY ST
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01020-1929
Mailing Address - Country:US
Mailing Address - Phone:413-592-8099
Mailing Address - Fax:513-592-5839
Practice Address - Street 1:391 MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01020-1929
Practice Address - Country:US
Practice Address - Phone:413-592-8099
Practice Address - Fax:513-592-5839
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA212011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1426492OtherTRICARE
CA1426492OtherUNITED CONCORDIA
MAX11395OtherBCBS MASS