Provider Demographics
NPI:1699874453
Name:BOU ASSI, CARLOS (DMD)
Entity type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:
Last Name:BOU ASSI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10590 ENDURING FREEDOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5005
Mailing Address - Country:US
Mailing Address - Phone:315-772-6234
Mailing Address - Fax:315-774-3558
Practice Address - Street 1:10590 ENDURING FREEDOM DRIVE
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5005
Practice Address - Country:US
Practice Address - Phone:315-772-6234
Practice Address - Fax:315-774-3558
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH03622122300000X
MA21826122300000X
NJ22DI022992001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist