MEDICARE: DR. MICHAEL J BORUCHOV D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	026836	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1184724379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL J BORUCHOV D.D.S.

Provider Business Mailing Address
First Line	:	800 BROADWAY AVE
Second Line	:	SUITE A
City	:	HOLBROOK
State	:	NY
Zip	:	11741-4917
Country	:	US
Telephone Number	:	631-589-7402
Fax Number	:	631-563-0581

Provider Business Practice Location Address
First Line	:	800 BROADWAY AVE
Second Line	:	SUITE A
City	:	HOLBROOK
State	:	NY
Zip	:	11741-4917
Country	:	US
Telephone Number	:	631-589-7402
Fax Number	:	631-563-0581

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	07/08/2007

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