=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457489239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHADI BOUTROS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2007
-----------------------------------------------------
Last Update Date | 05/13/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 ALHAMBRA AVE
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-3156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-370-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2500 ALHAMBRA AVE
-----------------------------------------------------
City | MARTINEZ
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94553-3156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 925-370-5200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 54887
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------