Provider Demographics
NPI:1295169472
Name:BORUCHOV, RAFAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:RAFAEL
Middle Name:
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 1:11620 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 1:11620 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-7055
Practice Address - Country:US
Practice Address - Phone:718-507-7781
Practice Address - Fax:347-652-1760
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-24
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY50056907122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist