=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932601051
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MINA BOULES DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2018
-----------------------------------------------------
Last Update Date | 03/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2771 E LINCOLN HWY
-----------------------------------------------------
City | COATESVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19320-2461
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-383-1600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 COTTON ST APT 331
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19127-1557
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | DS041555
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------