Provider Demographics
NPI:1962124495
Name:BOUTROS, ANASTASIA ADEL (DMD)
Entity type:Individual
Prefix:DR
First Name:ANASTASIA
Middle Name:ADEL
Last Name:BOUTROS
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 1:6641 SILENT HARBOR DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2643
Mailing Address - Country:US
Mailing Address - Phone:714-926-6249
Mailing Address - Fax:
Practice Address - Street 1:4443 CANDLEWOOD ST
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1736
Practice Address - Country:US
Practice Address - Phone:562-634-5042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1080141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice