Healthcare Provider Details

I. General information

NPI: 1437229093
Provider Name (Legal Business Name): FREDERICK M BOURGEOIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43 BRIDGE ST
PELHAM NH
03076
US

IV. Provider business mailing address

15 IRON HORSE DR APT G310
BEDFORD NH
03110
US

V. Phone/Fax

Practice location:
  • Phone: 603-635-2151
  • Fax: 603-635-9924
Mailing address:
  • Phone: 603-606-1181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number17891
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3390
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: