Provider Demographics
NPI:1093961245
Name:BOUTSELIS, NICHOLAS JAMES (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:BOUTSELIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381R MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:TEWKSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01876
Mailing Address - Country:US
Mailing Address - Phone:978-640-1114
Mailing Address - Fax:978-640-1117
Practice Address - Street 1:381R MAIN STREET
Practice Address - Street 2:
Practice Address - City:TEWKSBURY
Practice Address - State:MA
Practice Address - Zip Code:01876
Practice Address - Country:US
Practice Address - Phone:978-640-1114
Practice Address - Fax:978-640-1117
Is Sole Proprietor?:No
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA185731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice