=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952566069
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH BOULOS DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2008
-----------------------------------------------------
Last Update Date | 01/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2180 GARNET AVE SUITE 1-K
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-3610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-270-4904
-----------------------------------------------------
Fax | 858-270-4275
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 663 S RANCHO SANTA FE RD SUITE # 342
-----------------------------------------------------
City | SAN MARCOS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92078-3973
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-355-8888
-----------------------------------------------------
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 | 58865
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------