Healthcare Provider Details

I. General information

NPI: 1295627115
Provider Name (Legal Business Name): ST. CLAIR ORAL AND MAXILLOFACIAL SURGERY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2025
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36610 HERITAGE DR
RICHMOND MI
48062-1937
US

IV. Provider business mailing address

36610 HERITAGE DR
RICHMOND MI
48062-1937
US

V. Phone/Fax

Practice location:
  • Phone: 586-727-6800
  • Fax: 586-727-6880
Mailing address:
  • Phone: 586-727-6800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. NICHOLAS JAMES BOURNIAS
Title or Position: OWNER/SURGEON
Credential: DDS
Phone: 248-882-3195