Provider Demographics
NPI:1639527716
Name:BOURGET, JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:BOURGET
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 1:1019 CAROLYN AVE
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37216-3611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:923 NASHVILLE PIKE STE A
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:TN
Practice Address - Zip Code:37066-4384
Practice Address - Country:US
Practice Address - Phone:615-241-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-30
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN103841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice