Provider Demographics
NPI:1811770472
Name:SEBASTIAN M BOURONCLE DDS4 FREDERICKSBURG PLLC
Entity type:Organization
Organization Name:SEBASTIAN M BOURONCLE DDS4 FREDERICKSBURG PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEBASTIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOURONCLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-898-1747
Mailing Address - Street 1:11111 LEAVELLS RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-5015
Mailing Address - Country:US
Mailing Address - Phone:540-898-1747
Mailing Address - Fax:
Practice Address - Street 1:11111 LEAVELLS RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-5015
Practice Address - Country:US
Practice Address - Phone:540-898-1747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEBASTIAN M BOURONCLE DDS4 FREDERICKSBURG PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental