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General NPI Number Information
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NPI Number | 1417967290
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Entity Type | Organization
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Legal Business Name | BRADLEY D. BOURCY DDS MS AND RYAN D. HARBERTSON DDS MS
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 01/10/2014
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Provider Practice Location Address
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Address Line | 850 E. GRAND AVENUE SUITE A
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City | ESCONDIDO
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State | CA
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Zip | 92025-3435
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Country | US
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Telephone | 760-741-4061
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Fax | 760-432-8764
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Provider Business Mailing Address
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Address Line | 850 E. GRAND AVENUE SUITE A
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City | ESCONDIDO
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State | CA
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Zip | 92025-3435
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Country | US
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Telephone | 760-741-4061
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Fax | 760-432-8764
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Authorized Official
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Title or Position | OWNER/PARTNER
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Name | RYAN D. HARBERTSON
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Credential | D.D.S., M.S.
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Telephone | 760-741-4061
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 042637
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License Number State | CA
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