Provider Demographics
NPI:1467574608
Name:BOURDEAU, LARRY G (DDS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:BOURDEAU
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:PO BOX 162
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:MI
Mailing Address - Zip Code:49870-0162
Mailing Address - Country:US
Mailing Address - Phone:906-563-9291
Mailing Address - Fax:
Practice Address - Street 1:510 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:MI
Practice Address - Zip Code:49870
Practice Address - Country:US
Practice Address - Phone:906-563-9291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID120190122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist