Healthcare Provider Details

I. General information

NPI: 1679540710
Provider Name (Legal Business Name): THOMAS J. BORRIS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 WETZEL AVE BUILDING #815
FORT CARSON CO
80913-4095
US

IV. Provider business mailing address

7927 BUSCHBORN RD
PEYTON CO
80831-7934
US

V. Phone/Fax

Practice location:
  • Phone: 719-526-7100
  • Fax: 719-526-7995
Mailing address:
  • Phone: 719-526-7100
  • Fax: 719-526-7995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number18444
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8616
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: