Healthcare Provider Details

I. General information

NPI: 1982107868
Provider Name (Legal Business Name): BORIS LA NOIRE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9130 ALCOSTA BLVD STE A
SAN RAMON CA
94583-3847
US

IV. Provider business mailing address

4870 GENEVA AVE
CONCORD CA
94521-2227
US

V. Phone/Fax

Practice location:
  • Phone: 925-230-9414
  • Fax: 925-803-2568
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number102327
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number102327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: