Provider Demographics
NPI:1184724379
Name:BORUCHOV, MICHAEL J (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:BORUCHOV
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 1:800 BROADWAY AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11741-4917
Mailing Address - Country:US
Mailing Address - Phone:631-589-7402
Mailing Address - Fax:631-563-0581
Practice Address - Street 1:800 BROADWAY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HOLBROOK
Practice Address - State:NY
Practice Address - Zip Code:11741-4917
Practice Address - Country:US
Practice Address - Phone:631-589-7402
Practice Address - Fax:631-563-0581
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0268361223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00661289Medicaid