Provider Demographics
NPI:1467902155
Name:BOULOS, BASSEL
Entity Type:Individual
Prefix:
First Name:BASSEL
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03076-3422
Mailing Address - Country:US
Mailing Address - Phone:603-931-4698
Mailing Address - Fax:
Practice Address - Street 1:1290 TREMONT ST
Practice Address - Street 2:
Practice Address - City:ROXBURY
Practice Address - State:MA
Practice Address - Zip Code:02120-3432
Practice Address - Country:US
Practice Address - Phone:617-427-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH045201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice