Sidney Lawrence Bourgeois Jr., D.D.S.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

056936 Issued in NY

Practice address

800 Irving Avenue (160)
Syracuse, NY 13210

Phone

(315) 425-2468

Fax

(315) 425-4415

NPI assigned

May 30, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 4

Addresses

Medicare fee-for-service enrollment

Enrolled in NY

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1117411200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1627430400000",
    "number": "1629071154",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "800 IRVING AVENUE (160)",
            "city": "SYRACUSE",
            "state": "NY",
            "postal_code": "13210",
            "telephone_number": "315-425-2468",
            "fax_number": "315-425-4415"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "800 IRVING AVENUE (160)",
            "city": "SYRACUSE",
            "state": "NY",
            "postal_code": "13210",
            "telephone_number": "315-425-2468",
            "fax_number": "315-425-4415"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "Syracuse Oral and Maxillofacial Surgery",
            "address_2": "516 East Genesee Street",
            "address_purpose": "LOCATION",
            "city": "Fayetteville",
            "state": "NY",
            "postal_code": "13066",
            "country_code": "US",
            "telephone_number": "315-637-4476",
            "fax_number": "315-637-1261",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "Syracuse Oral and Maxillofacial Surgery",
            "address_2": "578 Seneca Street",
            "address_purpose": "LOCATION",
            "city": "Oneida",
            "state": "NY",
            "postal_code": "13421",
            "country_code": "US",
            "telephone_number": "315-363-8233",
            "fax_number": "315-363-5043",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOURGEOIS",
        "first_name": "SIDNEY",
        "middle_name": "LAWRENCE",
        "name_prefix": "Dr.",
        "name_suffix": "Jr.",
        "credential": "D.D.S.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-05-30",
        "last_updated": "2021-07-28",
        "certification_date": "2021-07-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "TX",
            "license": "22617",
            "primary": false
        },
        {
            "code": "204E00000X",
            "taxonomy_group": "",
            "desc": "Oral & Maxillofacial Surgery",
            "state": "NY",
            "license": "056936",
            "primary": false
        },
        {
            "code": "204E00000X",
            "taxonomy_group": "",
            "desc": "Oral & Maxillofacial Surgery",
            "state": "TX",
            "license": "22617",
            "primary": false
        },
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NY",
            "license": "056936",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Fouad S Boulos, MD
• Karen Ann Boulos, ANP
• Nathan Bourcy
• George Bourdages
• Sara Bourdages
• Rachel Ashley Bousson, LMHC
• Christina Evale Bova, MPS, PT
• Gary Robert Bova
• Kim Bova, NP
• Lauren Talbot Bova, NP

• Oral and Maxillofacial Surgery (Dentist) in Syracuse, NY
• Providers in Syracuse, NY by specialty
• Oral and Maxillofacial Surgery (Dentist) in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.