Provider Demographics
NPI:1023308392
Name:BOULOS DENTAL CARE, P.C.
Entity type:Organization
Organization Name:BOULOS DENTAL CARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST (DDS)
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMY
Authorized Official - Middle Name:WASFY YOUSEF
Authorized Official - Last Name:BOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-465-7210
Mailing Address - Street 1:110 CARLSON PKWY
Mailing Address - Street 2:APT #115
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-5334
Mailing Address - Country:US
Mailing Address - Phone:952-465-7210
Mailing Address - Fax:
Practice Address - Street 1:470 HIGHWAY 96 W
Practice Address - Street 2:SUITE 200
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-1996
Practice Address - Country:US
Practice Address - Phone:952-465-7210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-07
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12329302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization