Healthcare Provider Details

I. General information

NPI: 1043216435
Provider Name (Legal Business Name): MARTIN R. BOORIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1087 WESTMINSTER AVE
DIX HILLS NY
11746-6340
US

IV. Provider business mailing address

P.O. BOX 107
HUNTINGTON STATION NY
11746
US

V. Phone/Fax

Practice location:
  • Phone: 516-776-0716
  • Fax: 631-940-7227
Mailing address:
  • Phone: 631-940-3690
  • Fax: 631-940-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number039997
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22DIO1606400
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number7066
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number039997
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number7006
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number220101606400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: