Provider Demographics
NPI:1770649337
Name:BORQUEZ, RANDOLPH ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:ANTHONY
Last Name:BORQUEZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12440 FIRESTONE BLVD
Mailing Address - Street 2:SUITE 1018
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-4328
Mailing Address - Country:US
Mailing Address - Phone:562-863-4333
Mailing Address - Fax:562-863-0533
Practice Address - Street 1:12440 FIRESTONE BLVD
Practice Address - Street 2:SUITE 1018
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-4328
Practice Address - Country:US
Practice Address - Phone:562-863-4333
Practice Address - Fax:562-863-0533
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA300821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB30082-01OtherDENTI-CAL
CACA00XXXXX49940000000OtherDELTA DENTAL
CACA00XXXXX49940000000OtherDELTA DENTAL