Provider Demographics
NPI:1417152125
Name:BOUTROS, JUDY ANDREA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:ANDREA
Last Name:BOUTROS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 COPPERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-1333
Mailing Address - Country:US
Mailing Address - Phone:419-206-9289
Mailing Address - Fax:
Practice Address - Street 1:7303 COPPERWOOD LN
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-1333
Practice Address - Country:US
Practice Address - Phone:419-206-9289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300211051223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics