MEDICARE: DR. LYLE BRUCE BORMAN 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	1223G0001X	General Practice Dentistry	034299	NY

General Provider Information

NPI Number	:	1407849847
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LYLE BRUCE BORMAN D.D.S.

Provider Business Mailing Address
First Line	:	9229 QUEENS BLVD
Second Line	:	SUITE 1K
City	:	REGO PARK
State	:	NY
Zip	:	11374-1056
Country	:	US
Telephone Number	:	718-459-1716
Fax Number	:	718-275-9841

Provider Business Practice Location Address
First Line	:	9229 QUEENS BLVD
Second Line	:	SUITE 1K
City	:	REGO PARK
State	:	NY
Zip	:	11374-1056
Country	:	US
Telephone Number	:	718-459-1716
Fax Number	:	718-275-9841

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

Provider Enumeration Date	:	08/30/2005
Last Update Date	:	07/08/2007

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