Provider Demographics
NPI:1679190342
Name:BOULOS, NARDEEN (DMD)
Entity Type:Individual
Prefix:
First Name:NARDEEN
Middle Name:
Last Name:BOULOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 BILLINGS AVE
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-3127
Mailing Address - Country:US
Mailing Address - Phone:949-521-9854
Mailing Address - Fax:
Practice Address - Street 1:1695 S SAN JACINTO AVE STE N
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-5104
Practice Address - Country:US
Practice Address - Phone:949-521-9854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist