Provider Demographics
NPI:1700043064
Name:MA BOULE DMD PC
Entity Type:Organization
Organization Name:MA BOULE DMD PC
Other - Org Name:BOULE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:BOULE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-552-3410
Mailing Address - Street 1:3910 TURNER AVE
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:IL
Mailing Address - Zip Code:60545-9727
Mailing Address - Country:US
Mailing Address - Phone:630-552-3410
Mailing Address - Fax:630-552-1543
Practice Address - Street 1:3910 TURNER AVE
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:IL
Practice Address - Zip Code:60545-9727
Practice Address - Country:US
Practice Address - Phone:630-552-3410
Practice Address - Fax:630-552-1543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190263131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty