Provider Demographics
NPI:1184806010
Name:GREGORY N BORGANELLI DMD PA
Entity type:Organization
Organization Name:GREGORY N BORGANELLI DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:N
Authorized Official - Last Name:BORGANELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PA
Authorized Official - Phone:386-752-8200
Mailing Address - Street 1:875 SW STATE RD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025
Mailing Address - Country:US
Mailing Address - Phone:386-752-8200
Mailing Address - Fax:386-752-8209
Practice Address - Street 1:875 SW STATE RD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025
Practice Address - Country:US
Practice Address - Phone:386-752-8200
Practice Address - Fax:386-752-8209
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN122711223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty