Samy Wasfy Boulos, DDS

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

D12329 Issued in MN

Practice address

470 Highway 96 W Ste 200
Shoreview, MN 55126-3214

Phone

(651) 366-6880

Fax

(651) 366-6881

NPI assigned

Apr 3, 2009

Sex

Male

Sole proprietor

No

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Turtle Cove Dental

  • Dental Clinic/Center
  • Rogers, MN
  • NPI 1952867046
  NPD (past) Authorized official
• Lee Prohofsky DDS PA

  • General Practice Dentistry
  • Rogers, MN
  • NPI 1215097134

  General Practice

  NPD (past)

Medicare fee-for-service enrollment

Enrolled in MN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Practice roles

The complete NPPES record for this NPI in the NPI Registry API format, last updated by the provider on Feb 14, 2019.

{
    "created_epoch": "1238716800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1550102400000",
    "number": "1275775348",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "470 HIGHWAY 96 W STE 200",
            "city": "SHOREVIEW",
            "state": "MN",
            "postal_code": "551263214",
            "telephone_number": "651-366-6880",
            "fax_number": "651-366-6881"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "470 HIGHWAY 96 W STE 200",
            "city": "SHOREVIEW",
            "state": "MN",
            "postal_code": "551263214",
            "telephone_number": "651-366-6880",
            "fax_number": "651-366-6881"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "14000 Northdale Blvd Ste J",
            "address_purpose": "LOCATION",
            "city": "Rogers",
            "state": "MN",
            "postal_code": "553744663",
            "country_code": "US",
            "telephone_number": "763-428-2300",
            "fax_number": "763-428-4031",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOULOS",
        "first_name": "SAMY",
        "middle_name": "WASFY",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-04-03",
        "last_updated": "2019-02-14",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MN",
            "license": "D12329",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Courtney Boland
• Jeffrey Bonsell, DC
• Percy Botchway, ATC
• Boulos Dental Care, P.C.
• Mina Samy Boulos, DDS
• Lauren Brodzinski
• Daniel J Brown, DC
• Jill Marie Buckingham, DTR, LICSW
• Susan Lienemann Buesing, LMFT LD MEPD
• Fardawsa Mohamed Bulhan

• All providers in Shoreview, MN
• General Practice Dentistry in Minnesota

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 14, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.