Provider Demographics
NPI:1073009767
Name:BOUTEHSAZ, ARMIN (DDS)
Entity Type:Individual
Prefix:DR
First Name:ARMIN
Middle Name:
Last Name:BOUTEHSAZ
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:1253 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21223-2684
Practice Address - Country:US
Practice Address - Phone:410-727-4746
Practice Address - Fax:410-727-6767
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD16564122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD767008700Medicaid
965375292OtherADA