MEDICARE: DR. TINA BOURGOIN D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	4383	ME

General Provider Information

NPI Number	:	1942616198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TINA BOURGOIN D.M.D.

Provider Business Mailing Address
First Line	:	271 MAIN ST
Second Line	:
City	:	MACHIAS
State	:	ME
Zip	:	04654-3606
Country	:	US
Telephone Number	:	207-255-8601
Fax Number	:	207-255-8694

Provider Business Practice Location Address
First Line	:	271 MAIN ST
Second Line	:
City	:	MACHIAS
State	:	ME
Zip	:	04654-3606
Country	:	US
Telephone Number	:	207-255-8601
Fax Number	:	207-255-8694

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2014
Last Update Date	:	07/09/2014

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