Provider Demographics
NPI:1689916504
Name:BORETSKY, BRUCE A (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BORETSKY
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 1:7310 N LAKE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1698
Mailing Address - Country:US
Mailing Address - Phone:706-653-2600
Mailing Address - Fax:706-494-1000
Practice Address - Street 1:7310 N LAKE DR
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1698
Practice Address - Country:US
Practice Address - Phone:706-653-2600
Practice Address - Fax:706-494-1000
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0121091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics