MEDICARE: DR. BRUCE A BORETSKY DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	DN012109	GA

General Provider Information

NPI Number	:	1689916504
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE A BORETSKY DMD

Provider Business Mailing Address
First Line	:	7310 N LAKE DR
Second Line	:	SUITE C
City	:	COLUMBUS
State	:	GA
Zip	:	31909-1698
Country	:	US
Telephone Number	:	706-653-2600
Fax Number	:	706-494-1000

Provider Business Practice Location Address
First Line	:	7310 N LAKE DR
Second Line	:	SUITE C
City	:	COLUMBUS
State	:	GA
Zip	:	31909-1698
Country	:	US
Telephone Number	:	706-653-2600
Fax Number	:	706-494-1000

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2013
Last Update Date	:	03/18/2013

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