Provider Demographics
NPI:1801835954
Name:BOURGEOIS, FREDERICK WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:WAYNE
Last Name:BOURGEOIS
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 1:5400 N HIGH ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-1117
Mailing Address - Country:US
Mailing Address - Phone:614-436-2817
Mailing Address - Fax:614-436-3954
Practice Address - Street 1:5400 N HIGH ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-1117
Practice Address - Country:US
Practice Address - Phone:614-436-2817
Practice Address - Fax:614-436-3954
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0153991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice