MEDICARE: DR. CATHERINE BOULOS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	045193-1	NY

General Provider Information

NPI Number	:	1376797449
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CATHERINE BOULOS DDS

Provider Business Mailing Address
First Line	:	131 BARBARA ST
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10306-1827
Country	:	US
Telephone Number	:	718-980-9472
Fax Number	:	718-980-9472

Provider Business Practice Location Address
First Line	:	1432 FOREST AVE
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10302-2204
Country	:	US
Telephone Number	:	718-442-9254
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2008
Last Update Date	:	11/15/2008

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