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General NPI Number Information
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NPI Number | 1023308392
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Entity Type | Organization
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Legal Business Name | BOULOS DENTAL CARE, P.C.
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 04/07/2011
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Provider Practice Location Address
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Address Line | 470 HIGHWAY 96 W SUITE 200
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City | SHOREVIEW
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State | MN
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Zip | 55126-1996
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Country | US
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Telephone | 952-465-7210
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Fax |
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Provider Business Mailing Address
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Address Line | 110 CARLSON PKWY APT #115
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City | MINNETONKA
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State | MN
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Zip | 55305-5334
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Country | US
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Telephone | 952-465-7210
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Fax |
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Authorized Official
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Title or Position | DENTIST (DDS)
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Name | DR. SAMY WASFY YOUSEF BOULOS
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Credential |
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Telephone | 952-465-7210
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | 12329
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License Number State | MN
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