Provider Demographics
NPI:1417967290
Name:BRADLEY D. BOURCY DDS MS AND RYAN D. HARBERTSON DDS MS
Entity Type:Organization
Organization Name:BRADLEY D. BOURCY DDS MS AND RYAN D. HARBERTSON DDS MS
Other - Org Name:DAVID L. TAGGE, D.D.S., M.S.D. AND BRADLEY D. BOURCY, D.D.S., M.S., IN
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARBERTSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:760-741-4061
Mailing Address - Street 1:850 E. GRAND AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3435
Mailing Address - Country:US
Mailing Address - Phone:760-741-4061
Mailing Address - Fax:760-432-8764
Practice Address - Street 1:850 E. GRAND AVENUE
Practice Address - Street 2:SUITE A
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3435
Practice Address - Country:US
Practice Address - Phone:760-741-4061
Practice Address - Fax:760-432-8764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0426371223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty