MEDICARE: DR. CARLOS BOU ASSI DMD

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	03622	NH
2	122300000X	Dentist	21826	MA
3	1223G0001X	General Practice Dentistry	22DI02299200	NJ

General Provider Information

NPI Number	:	1699874453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLOS BOU ASSI DMD

Provider Business Mailing Address
First Line	:	10590 ENDURING FREEDOM DRIVE
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5005
Country	:	US
Telephone Number	:	315-772-6234
Fax Number	:	315-774-3558

Provider Business Practice Location Address
First Line	:	10590 ENDURING FREEDOM DRIVE
Second Line	:
City	:	FORT DRUM
State	:	NY
Zip	:	13602-5005
Country	:	US
Telephone Number	:	315-772-6234
Fax Number	:	315-774-3558

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	04/09/2015

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