MEDICARE: DR. DAVID R BOURQUE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	37469	NY

General Provider Information

NPI Number	:	1427050624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID R BOURQUE DDS

Provider Business Mailing Address
First Line	:	57 MAIN ST
Second Line	:
City	:	AKRON
State	:	NY
Zip	:	14001-1239
Country	:	US
Telephone Number	:	716-542-2895
Fax Number	:	716-542-6921

Provider Business Practice Location Address
First Line	:	57 MAIN ST
Second Line	:
City	:	AKRON
State	:	NY
Zip	:	14001-1239
Country	:	US
Telephone Number	:	716-542-2895
Fax Number	:	716-542-6921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/01/2005
Last Update Date	:	01/14/2013

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