Provider Demographics
NPI:1356558845
Name:TIMOTHY G. BOURDON, DDS, LLC
Entity type:Organization
Organization Name:TIMOTHY G. BOURDON, DDS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:BOURDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:719-542-1212
Mailing Address - Street 1:902 W 29TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1159
Mailing Address - Country:US
Mailing Address - Phone:719-542-1212
Mailing Address - Fax:719-545-5525
Practice Address - Street 1:902 W 29TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-1159
Practice Address - Country:US
Practice Address - Phone:719-542-1212
Practice Address - Fax:719-545-5525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1058211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty