Healthcare Provider Details

I. General information

NPI: 1912837774
Provider Name (Legal Business Name): MINA SAMY BOULOS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 HIGHWAY 96 W STE 200
SHOREVIEW MN
55126-3214
US

IV. Provider business mailing address

7702 NARCISSUS LN N
MAPLE GROVE MN
55311-1849
US

V. Phone/Fax

Practice location:
  • Phone: 651-366-6880
  • Fax: 651-366-6880
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD15431
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: