Provider Demographics
NPI:1003946518
Name:BOURJAILY, RANDAL ALAN (DDS)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:ALAN
Last Name:BOURJAILY
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 1:37470 E MEADOWHILL DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-9018
Mailing Address - Country:US
Mailing Address - Phone:248-471-3628
Mailing Address - Fax:
Practice Address - Street 1:30900 BECK RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-1001
Practice Address - Country:US
Practice Address - Phone:248-669-4030
Practice Address - Fax:248-669-3530
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0123531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice