Provider Demographics
NPI:1316903800
Name:BORCHARDT, MARTIN HOWARD (DDS)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:HOWARD
Last Name:BORCHARDT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 FRANCE AVE S STE 415
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-1817
Mailing Address - Country:US
Mailing Address - Phone:952-224-9771
Mailing Address - Fax:952-224-9790
Practice Address - Street 1:8711 E POINT DOUGLAS RD S
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55016-5000
Practice Address - Country:US
Practice Address - Phone:651-379-9892
Practice Address - Fax:651-379-9893
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND11739122300000X
WI4567015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN549720500Medicaid