Provider Demographics
NPI:1710016175
Name:JOHN-BORDE, JENNIFER F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:F
Last Name:JOHN-BORDE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BIRCHWOOD DR N
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-1905
Mailing Address - Country:US
Mailing Address - Phone:516-872-4052
Mailing Address - Fax:516-872-2739
Practice Address - Street 1:9050 FRANCIS LEWIS BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1069
Practice Address - Country:US
Practice Address - Phone:718-740-4700
Practice Address - Fax:718-740-4716
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040626-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02120065Medicaid