=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710016175
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER F JOHN-BORDE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9050 FRANCIS LEWIS BLVD
-----------------------------------------------------
City | QUEENS VILLAGE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11428-1069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-740-4700
-----------------------------------------------------
Fax | 718-740-4716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 BIRCHWOOD DR N
-----------------------------------------------------
City | VALLEY STREAM
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11580-1905
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-872-4052
-----------------------------------------------------
Fax | 516-872-2739
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 040626-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------