Provider Demographics
NPI:1215596705
Name:BORISOV, IGOR (DMD)
Entity Type:Individual
Prefix:DR
First Name:IGOR
Middle Name:
Last Name:BORISOV
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 1:1155 W ELLIOT RD APT 3113
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1184
Mailing Address - Country:US
Mailing Address - Phone:410-905-9992
Mailing Address - Fax:
Practice Address - Street 1:44480 W HONEYCUTT RD STE 110
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-2909
Practice Address - Country:US
Practice Address - Phone:520-568-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD010359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist