Provider Demographics
NPI:1790968733
Name:BORNSTEIN, MARK M (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:M
Last Name:BORNSTEIN
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 1:633 BARNARD AVE
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2728
Mailing Address - Country:US
Mailing Address - Phone:347-229-4628
Mailing Address - Fax:
Practice Address - Street 1:1847 MOTT AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4201
Practice Address - Country:US
Practice Address - Phone:347-229-4628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY052254122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist