Provider Demographics
NPI:1548230865
Name:BORDEN, GARY E (DDS MS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:E
Last Name:BORDEN
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 DAVIS ST
Mailing Address - Street 2:#509
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-869-9303
Mailing Address - Fax:847-869-9323
Practice Address - Street 1:500 DAVIS ST
Practice Address - Street 2:#509
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-869-9303
Practice Address - Fax:847-869-9323
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
696560Medicare ID - Type Unspecified
T37947Medicare UPIN