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General NPI Number Information
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NPI Number | 1972733053
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Entity Type | Organization
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Legal Business Name | REACHING OUT MINISTRIES
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Dates
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Enumeration Date | 07/22/2009
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Last Update Date | 07/22/2009
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Provider Practice Location Address
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Address Line | 226 CHALAN SAN ANTONIO STE C AMPARO'S BUSINESS CENTER
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City | TAMUNING
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State | GU
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Zip | 96913-3525
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Country | US
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Telephone | 671-646-2010
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Fax | 671-646-2070
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Provider Business Mailing Address
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Address Line | 226 CHALAN SAN ANTONIO STE C AMPARO'S BUSINESS CENTER
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City | TAMUNING
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State | GU
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Zip | 96913-3525
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Country | US
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Telephone | 671-646-2010
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Fax | 671-646-2070
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Authorized Official
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Title or Position | PRESIDENT/PRIMARY DENTAL PROVIDER
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Name | DR. KENNY WAYNE BOURGEOIS
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Credential | DDS
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Telephone | 671-646-2010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 14605
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D927
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License Number State | GU
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