Individual
MR. MATTHEW EDWARD BOURG
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
17236 SE STARK ST, PORTLAND, OR 97233-4546
(503) 254-1260
(503) 254-1494
Mailing address
17236 SE STARK ST, PORTLAND, OR 97233-4546
(503) 254-1260
(503) 254-1494
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D6261
OR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
117721
—
OR
Enumeration date
10/11/2006
Last updated
07/08/2007
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