Healthcare Provider Details

I. General information

NPI: 1649322561
Provider Name (Legal Business Name): CHARLES SEYMOUR BORDEN III DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 SAINT LOUIS RD
COLLINSVILLE IL
62234-2032
US

IV. Provider business mailing address

4918 MILLER LN
EDWARDSVILLE IL
62025-5866
US

V. Phone/Fax

Practice location:
  • Phone: 618-344-8533
  • Fax:
Mailing address:
  • Phone: 618-692-9096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2003018445
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: