Provider Demographics
NPI:1063562072
Name:BOUTROS, NANCY MARY (DDS DOCTOR OF DENTAL)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MARY
Last Name:BOUTROS
Suffix:
Gender:F
Credentials:DDS DOCTOR OF DENTAL
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:MARK
Other - Last Name:YOUSSEF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS DOCTOR OF DENTAL
Mailing Address - Street 1:608 10TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90402
Mailing Address - Country:US
Mailing Address - Phone:310-393-2054
Mailing Address - Fax:310-393-2054
Practice Address - Street 1:1381 E LAS JUNAS DR
Practice Address - Street 2:SUITE #8
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776
Practice Address - Country:US
Practice Address - Phone:626-614-5800
Practice Address - Fax:626-614-9570
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA42809122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist