Provider Demographics
NPI:1114182029
Name:BOUSTANY, CHAD M (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:M
Last Name:BOUSTANY
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 1:152 MEADOWRIDGE TOWNHOMES
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:152 MEADOWRIDGE TOWNHOMES
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505
Practice Address - Country:US
Practice Address - Phone:304-599-1478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3842122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist