Provider Demographics
NPI:1255561320
Name:BOURGEOIS, KENNETH WAYNE (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
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 1:226 CHALAN SAN ANTONIO STE C
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913-3525
Mailing Address - Country:US
Mailing Address - Phone:671-646-2010
Mailing Address - Fax:671-646-2070
Practice Address - Street 1:226 CHALAN SAN ANTONIO STE C
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913-3525
Practice Address - Country:US
Practice Address - Phone:671-646-2010
Practice Address - Fax:671-646-2070
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GUD9271223G0001X
TX146051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice