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General NPI Number Information
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NPI Number | 1043378722
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Entity Type | Individual
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Provider Name | MICHAEL JOSEPH BOULE DOCTOR OF DENTAL SUR
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Gender | Male
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 134 BRINKERHOFF STREET
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City | PLATTSBURGH
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State | NY
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Zip | 12901
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Country | US
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Telephone | 518-563-3090
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Fax | 518-563-5455
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Provider Business Mailing Address
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Address Line | 240 JABEZ ALLEN ROAD
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City | PERU
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State | NY
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Zip | 12972
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Country | US
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Telephone | 518-643-0224
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 48160
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License Number State | NY
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