=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073998480
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAMES BOURNE DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2015
-----------------------------------------------------
Last Update Date | 07/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3732 BEN WALTERS LN
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-8574
-----------------------------------------------------
Fax | 907-235-7593
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3732 BEN WALTERS LN
-----------------------------------------------------
City | HOMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99603-7704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-235-8574
-----------------------------------------------------
Fax | 907-235-7593
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAMES RANDALL BOURNE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 907-235-8574
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | AK1516
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------