Healthcare Provider Details

I. General information

NPI: 1700131190
Provider Name (Legal Business Name): WAEL BORHAM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2012
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 S ALAMEDA BLVD
LAS CRUCES NM
88005-2817
US

IV. Provider business mailing address

608 S ALAMEDA BLVD
LAS CRUCES NM
88005-2817
US

V. Phone/Fax

Practice location:
  • Phone: 575-523-5589
  • Fax:
Mailing address:
  • Phone: 575-523-5589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number61443
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4473
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: