Provider Demographics
NPI:1952566069
Name:BOULOS, JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 S RANCHO SANTA FE RD
Mailing Address - Street 2:SUITE # 342
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-3973
Mailing Address - Country:US
Mailing Address - Phone:734-355-8888
Mailing Address - Fax:
Practice Address - Street 1:2180 GARNET AVE
Practice Address - Street 2:SUITE 1-K
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3610
Practice Address - Country:US
Practice Address - Phone:858-270-4904
Practice Address - Fax:858-270-4275
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-29
Last Update Date:2011-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58865122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist