Provider Demographics
NPI:1821681164
Name:GHOBRIAL, PIERRE BASSEM BOULOS (DMD)
Entity Type:Individual
Prefix:
First Name:PIERRE
Middle Name:BASSEM BOULOS
Last Name:GHOBRIAL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6710 VARIEL AVE APT 233
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91303-4801
Mailing Address - Country:US
Mailing Address - Phone:857-654-8318
Mailing Address - Fax:
Practice Address - Street 1:7125 N DURANGO DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-4466
Practice Address - Country:US
Practice Address - Phone:702-658-2311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-18
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105974122300000X
CT2.012997122300000X
MADN1858898122300000X
TX37000122300000X
NV7437122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist