Provider Demographics
NPI:1518330463
Name:CAPITOL ENDODONTICS, PLLC
Entity Type:Organization
Organization Name:CAPITOL ENDODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUSTANY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:304-345-1248
Mailing Address - Street 1:405 CAPITOL ST
Mailing Address - Street 2:SUITE 914
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1749
Mailing Address - Country:US
Mailing Address - Phone:304-345-1248
Mailing Address - Fax:
Practice Address - Street 1:405 CAPITOL ST
Practice Address - Street 2:SUITE 914
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1749
Practice Address - Country:US
Practice Address - Phone:304-345-1248
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-01
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV41801223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty