Provider Demographics
NPI:1962644229
Name:BOERNER, RICHARD YALE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:YALE
Last Name:BOERNER
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 1:270 BRISTOL ST STE 106
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5936
Mailing Address - Country:US
Mailing Address - Phone:714-434-7100
Mailing Address - Fax:714-434-7431
Practice Address - Street 1:270 BRISTOL ST STE 106
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5936
Practice Address - Country:US
Practice Address - Phone:714-434-7100
Practice Address - Fax:714-434-7431
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist