Provider Demographics
NPI:1760674030
Name:BOURGEOIS, KERRI A (DMD)
Entity Type:Individual
Prefix:DR
First Name:KERRI
Middle Name:A
Last Name:BOURGEOIS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 WOODSIDE LN
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02474-2152
Mailing Address - Country:US
Mailing Address - Phone:781-646-9894
Mailing Address - Fax:
Practice Address - Street 1:1864 CENTRE ST STE 2
Practice Address - Street 2:
Practice Address - City:WEST ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02132-1919
Practice Address - Country:US
Practice Address - Phone:617-390-5371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN22202122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist