Provider Demographics
NPI:1588977623
Name:BOUTSIKOS, MARIA (DMD)
Entity type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:BOUTSIKOS
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 N PARK RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-2526
Mailing Address - Country:US
Mailing Address - Phone:954-610-9242
Mailing Address - Fax:
Practice Address - Street 1:7351 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-7107
Practice Address - Country:US
Practice Address - Phone:954-742-5055
Practice Address - Fax:954-742-5341
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19144122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist