Provider Demographics
NPI:1043378722
Name:BOULE, MICHAEL JOSEPH (DOCTOR OF DENTAL SUR)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JOSEPH
Last Name:BOULE
Suffix:
Gender:M
Credentials:DOCTOR OF DENTAL SUR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:240 JABEZ ALLEN ROAD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NY
Mailing Address - Zip Code:12972
Mailing Address - Country:US
Mailing Address - Phone:518-643-0224
Mailing Address - Fax:
Practice Address - Street 1:134 BRINKERHOFF STREET
Practice Address - Street 2:
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12901
Practice Address - Country:US
Practice Address - Phone:518-563-3090
Practice Address - Fax:518-563-5455
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02568803Medicaid