Healthcare Provider Details

I. General information

NPI: 1780948794
Provider Name (Legal Business Name): TYLER DALE BORG D.D.S. , M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11178 HURON ST STE 100
NORTHGLENN CO
80234-3115
US

IV. Provider business mailing address

11178 HURON ST STE 100
NORTHGLENN CO
80234-3115
US

V. Phone/Fax

Practice location:
  • Phone: 303-457-9617
  • Fax:
Mailing address:
  • Phone: 303-457-9617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number202449
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: