Provider Demographics
NPI:1235475633
Name:MIGUEL FERNANDO BORDA, PA
Entity Type:Organization
Organization Name:MIGUEL FERNANDO BORDA, PA
Other - Org Name:BGR DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:BORDA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-226-9916
Mailing Address - Street 1:1825 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33406-8902
Mailing Address - Country:US
Mailing Address - Phone:561-733-9099
Mailing Address - Fax:
Practice Address - Street 1:2647 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-4840
Practice Address - Country:US
Practice Address - Phone:954-923-7348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-13
Last Update Date:2016-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN178521223E0200X
FLDN193921223G0001X
FLDN199241223G0001X
FLDN194691223G0001X
FLDN164821223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty