Provider Demographics
NPI:1962614610
Name:BRUCE A BORETSKY DMD, LLC
Entity type:Organization
Organization Name:BRUCE A BORETSKY DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BORETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:706-653-2600
Mailing Address - Street 1:7310 N LAKE DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2787
Mailing Address - Country:US
Mailing Address - Phone:706-653-2600
Mailing Address - Fax:706-494-1000
Practice Address - Street 1:7310 N LAKE DR
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-2787
Practice Address - Country:US
Practice Address - Phone:706-653-2600
Practice Address - Fax:706-494-1000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0121091223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty