Provider Demographics
NPI:1639391550
Name:BALOUL, SOULAFA SUSAN (DMD, MS, DSCD)
Entity type:Individual
Prefix:DR
First Name:SOULAFA
Middle Name:SUSAN
Last Name:BALOUL
Suffix:
Gender:F
Credentials:DMD, MS, DSCD
Other - Prefix:DR
Other - First Name:SOULAFA
Other - Middle Name:SUSAN
Other - Last Name:BALOUL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:6 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062-3504
Mailing Address - Country:US
Mailing Address - Phone:781-769-8000
Mailing Address - Fax:
Practice Address - Street 1:177 TREMONT ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1020
Practice Address - Country:US
Practice Address - Phone:617-617-7677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276431223X0400X
MADN206561223X0400X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics