MEDICARE: DR. CHARLES SEYMOUR BORDEN III DDS

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	122300000X	Dentist	2003018445	MO
2	122300000X	Dentist		IL

General Provider Information

NPI Number	:	1649322561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHARLES SEYMOUR BORDEN III DDS

Provider Business Mailing Address
First Line	:	4918 MILLER LN
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-5866
Country	:	US
Telephone Number	:	618-692-9096
Fax Number	:

Provider Business Practice Location Address
First Line	:	724 SAINT LOUIS RD
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-2032
Country	:	US
Telephone Number	:	618-344-8533
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	07/08/2007

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