Provider Demographics
NPI:1144202045
Name:BOURNIAS, NICHOLAS JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JAMES
Last Name:BOURNIAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:
Mailing Address - Fax:
Practice Address - Street 1:43900 GARFIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1137
Practice Address - Country:US
Practice Address - Phone:586-228-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010155731223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3203473Medicaid
MINB015573OtherLICENSE NUMBER
MI3159052Medicaid
MI970F31085OtherBCBSM
MI3159052Medicaid