Provider Demographics
NPI:1700926235
Name:BOURBEAU, DONALD ALFRED (DDS)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:ALFRED
Last Name:BOURBEAU
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:PO BOX 640
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-0640
Mailing Address - Country:US
Mailing Address - Phone:248-628-4050
Mailing Address - Fax:248-628-4051
Practice Address - Street 1:837 SOUTH LAPEER ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-5084
Practice Address - Country:US
Practice Address - Phone:248-628-4050
Practice Address - Fax:248-628-4051
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901010939122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAB8411299OtherST BOARD OF PHARMACY
MI10939OtherSTATE BOARD OF DENTISTRY