Provider Demographics
NPI:1932245511
Name:BOURONCLE, SEBASTIAN M (DDS)
Entity Type:Individual
Prefix:DR
First Name:SEBASTIAN
Middle Name:M
Last Name:BOURONCLE
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 1:42 DAVENPORT DR
Mailing Address - Street 2:APT # 303
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22554-7180
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 GARRISONVILLE RD
Practice Address - Street 2:SUITE 108
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-1545
Practice Address - Country:US
Practice Address - Phone:540-657-7645
Practice Address - Fax:540-657-1009
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014114661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice