Provider Demographics
NPI:1437571395
Name:HQ DENTAL PC
Entity Type:Organization
Organization Name:HQ DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORUCHOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:347-283-2396
Mailing Address - Street 1:11620 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7055
Mailing Address - Country:US
Mailing Address - Phone:347-283-2396
Mailing Address - Fax:
Practice Address - Street 1:11620 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7055
Practice Address - Country:US
Practice Address - Phone:347-283-2396
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03718852Medicaid