Healthcare Provider Details

I. General information

NPI: 1699874453
Provider Name (Legal Business Name): CARLOS BOU ASSI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 04/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 ENDURING FREEDOM DRIVE
FORT DRUM NY
13602-5005
US

IV. Provider business mailing address

10590 ENDURING FREEDOM DRIVE
FORT DRUM NY
13602-5005
US

V. Phone/Fax

Practice location:
  • Phone: 315-772-6234
  • Fax: 315-774-3558
Mailing address:
  • Phone: 315-772-6234
  • Fax: 315-774-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number03622
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number21826
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02299200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: