Healthcare Provider Details

I. General information

NPI: 1730211764
Provider Name (Legal Business Name): MELVIN ANTHONY BOULE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 TURNER AVE
PLANO IL
60545-9727
US

IV. Provider business mailing address

1879 ASTER DR
YORKVILLE IL
60560-5806
US

V. Phone/Fax

Practice location:
  • Phone: 630-552-3410
  • Fax:
Mailing address:
  • Phone: 630-553-2816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: