MEDICARE: MINA SAMY 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	1223G0001X	General Practice Dentistry	D15431	MN

General Provider Information

NPI Number	:	1912837774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINA SAMY BOULOS DDS

Provider Business Mailing Address
First Line	:	7702 NARCISSUS LN N
Second Line	:
City	:	MAPLE GROVE
State	:	MN
Zip	:	55311-1849
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	470 HIGHWAY 96 W STE 200
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-3214
Country	:	US
Telephone Number	:	651-366-6880
Fax Number	:	651-366-6880

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

Provider Enumeration Date	:	05/21/2026
Last Update Date	:	05/21/2026

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Directions to “ MINA SAMY BOULOS DDS” Practice Location

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