Provider Demographics
NPI:1750792180
Name:BOULES, DAVID (DMD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:BOULES
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 1:1425 NEW BOLTON DR
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-5327
Mailing Address - Country:US
Mailing Address - Phone:386-405-1108
Mailing Address - Fax:
Practice Address - Street 1:123 W PLYMOUTH AVE
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2721
Practice Address - Country:US
Practice Address - Phone:386-736-8865
Practice Address - Fax:386-736-6890
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20722122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist