Provider Demographics
NPI:1902994312
Name:BOURG, MATTHEW EDWARD (DMD)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:EDWARD
Last Name:BOURG
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17236 SE STARK ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-4546
Mailing Address - Country:US
Mailing Address - Phone:503-254-1260
Mailing Address - Fax:503-254-1494
Practice Address - Street 1:17236 SE STARK ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-4546
Practice Address - Country:US
Practice Address - Phone:503-254-1260
Practice Address - Fax:503-254-1494
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD6261122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR117721Medicaid