=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437571395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HQ DENTAL PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2014
-----------------------------------------------------
Last Update Date | 01/13/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11620 QUEENS BLVD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-283-2396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11620 QUEENS BLVD
-----------------------------------------------------
City | FOREST HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11375-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-283-2396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. RAFAEL BORUCHOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 347-283-2396
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 056907
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------