Provider Demographics
NPI:1235151630
Name:BOURNE, ROBERT RANDALL (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RANDALL
Last Name:BOURNE
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 1:1341 MT HIGHWAY 282
Mailing Address - Street 2:PO BOX 232
Mailing Address - City:CLANCY
Mailing Address - State:MT
Mailing Address - Zip Code:59634-9716
Mailing Address - Country:US
Mailing Address - Phone:406-495-8858
Mailing Address - Fax:
Practice Address - Street 1:1341 MT HIGHWAY 282
Practice Address - Street 2:
Practice Address - City:FORT HARRISON
Practice Address - State:MT
Practice Address - Zip Code:59636-0232
Practice Address - Country:US
Practice Address - Phone:406-447-7362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM930122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist