Organization Name: | BORELLO ORTHODONTICS |
NPI Number: | 1326356304 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | BLAKE BORELLO (OWNER) |
Mailing Address: | 6288 Ronald Reagan Dr. Lake Saint Louis |
State: | MO US |
Postal Code: | 63367 |
Phone Number: | 6366254224 |
Fax Number: | |
NPI Enumeration Date: | 09/23/2010 |
NPI Last Update Date: | 02/02/2011 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | 2008019644 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MO |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |