Provider Demographics
NPI:1871613497
Name:BOURNIAS, ALEXANDER L (DDS)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:L
Last Name:BOURNIAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:196 S SMITH ST
Mailing Address - City:COCHRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:16314-0065
Mailing Address - Country:US
Mailing Address - Phone:814-425-3706
Mailing Address - Fax:
Practice Address - Street 1:1015 GROVE ST
Practice Address - Street 2:
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-2905
Practice Address - Country:US
Practice Address - Phone:814-336-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020436L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA961361OtherBC BS NUMBER
PA1750346805OtherGROUP TYPE 2 NPI