Provider Demographics
NPI:1801800578
Name:BOURNS, MICHAEL (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:BOURNS
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 1:1202 HIGHWAY 35 N
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2328
Mailing Address - Country:US
Mailing Address - Phone:501-776-0620
Mailing Address - Fax:501-776-0844
Practice Address - Street 1:1202 HIGHWAY 35 N
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-2328
Practice Address - Country:US
Practice Address - Phone:501-776-0620
Practice Address - Fax:501-776-0844
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR22471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice