Provider Demographics
NPI:1922509348
Name:99 NASSAU AVE DENTAL PLLC
Entity Type:Organization
Organization Name:99 NASSAU AVE DENTAL PLLC
Other - Org Name:DENTAL MADE EASY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAFAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BORUCHOV
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-507-7781
Mailing Address - Street 1:11620 QUEENS BLVD
Mailing Address - Street 2:
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-7055
Mailing Address - Country:US
Mailing Address - Phone:718-507-7781
Mailing Address - Fax:
Practice Address - Street 1:99 NASSAU AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11222-3082
Practice Address - Country:US
Practice Address - Phone:718-383-0024
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY056907261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental