Provider Demographics
NPI:1699269233
Name:BOUSTANY, ADAM (DDS)
Entity type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:BOUSTANY
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 1:241 RAVEN RUN
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-9297
Mailing Address - Country:US
Mailing Address - Phone:304-941-7720
Mailing Address - Fax:
Practice Address - Street 1:2017 E PIKE ST
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-6013
Practice Address - Country:US
Practice Address - Phone:304-623-9188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV43381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice