Provider Demographics
NPI:1942616198
Name:BOURGOIN, TINA (DMD)
Entity type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:BOURGOIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-3606
Mailing Address - Country:US
Mailing Address - Phone:207-255-8601
Mailing Address - Fax:207-255-8694
Practice Address - Street 1:271 MAIN ST
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-3606
Practice Address - Country:US
Practice Address - Phone:207-255-8601
Practice Address - Fax:207-255-8694
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME4383122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist