=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245938208
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BOULA ZAKRIA ADLY MORKOS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2023
-----------------------------------------------------
Last Update Date | 10/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1200 SAVIERS RD
-----------------------------------------------------
City | OXNARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93033-1732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-248-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8442 HENDERSON RD
-----------------------------------------------------
City | VENTURA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93004-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-256-5354
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 109554
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------