Provider Demographics
NPI:1801136494
Name:BOURKLIAN, JACK (DDS)
Entity type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:BOURKLIAN
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 1:301 N SAN DIMAS CANYON RD
Mailing Address - Street 2:101
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-2741
Mailing Address - Country:US
Mailing Address - Phone:909-599-2023
Mailing Address - Fax:
Practice Address - Street 1:15290 BEAR VALLEY RD
Practice Address - Street 2:#B
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-8515
Practice Address - Country:US
Practice Address - Phone:760-951-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62218122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist