Provider Demographics
NPI:1386177848
Name:BOULOS, MINA (MD, DMD)
Entity type:Individual
Prefix:DR
First Name:MINA
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 ADOLPHUS AVE APT 1411
Mailing Address - Street 2:
Mailing Address - City:CLIFFSIDE PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07010-2856
Mailing Address - Country:US
Mailing Address - Phone:978-821-3822
Mailing Address - Fax:
Practice Address - Street 1:260 OLD HOOK RD BLDG SUITE202
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3123
Practice Address - Country:US
Practice Address - Phone:978-821-3822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI030265001223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty