Provider Demographics
NPI:1588879688
Name:BORST, LAURELYN (RDH)
Entity type:Individual
Prefix:
First Name:LAURELYN
Middle Name:
Last Name:BORST
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 MISSION AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3250
Mailing Address - Country:US
Mailing Address - Phone:415-457-1397
Mailing Address - Fax:
Practice Address - Street 1:2001 UNION ST
Practice Address - Street 2:SUITE 385
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-4114
Practice Address - Country:US
Practice Address - Phone:415-441-9760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAH2463124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA133069OtherDELTA DENTAL LICENSE NO.
CAH2463OtherRDH LICENSE #
CAH02463OtherMEDICAL PROVIDER NUMBER