Mina Boulos, M.D., D.M.D.

Primary specialty

Oral and Maxillofacial Surgery (Dentist)Taxonomy code 1223S0112X

License

22DI03026500 Issued in NJ

Practice address

260 Old Hook Rd BLDG Suite202
Westwood, NJ 07675-3123

Phone

(978) 821-3822

NPI assigned

Apr 11, 2017

Last updated

Aug 28, 2024By the provider in NPPES

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Enrolled in CT

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

Credentials

Doctor of Medicine

State licenses

Interoperability endpoints

• Direct secure messaging: mboulos1259819@ahs.direct-ci.com

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1491868800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724803200000",
    "number": "1386177848",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "320 ADOLPHUS AVE APT 1411",
            "city": "CLIFFSIDE PARK",
            "state": "NJ",
            "postal_code": "070102856",
            "telephone_number": "978-821-3822"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "260 OLD HOOK RD BLDG SUITE202",
            "city": "WESTWOOD",
            "state": "NJ",
            "postal_code": "076753123",
            "telephone_number": "978-821-3822"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "401 Hackensack Ave Ste 103",
            "address_purpose": "LOCATION",
            "city": "Hackensack",
            "state": "NJ",
            "postal_code": "076016445",
            "country_code": "US",
            "telephone_number": "978-821-3822",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "794 Franklin Ave Ste 202",
            "address_purpose": "LOCATION",
            "city": "Franklin Lakes",
            "state": "NJ",
            "postal_code": "074171399",
            "country_code": "US",
            "telephone_number": "978-821-8222",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "address_1": "1200 E Ridgewood Ave Ste 102",
            "address_purpose": "LOCATION",
            "city": "Ridgewood",
            "state": "NJ",
            "postal_code": "074503937",
            "country_code": "US",
            "telephone_number": "978-821-8222",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "BOULOS",
        "first_name": "MINA",
        "name_prefix": "Dr.",
        "credential": "M.D., D.M.D.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2017-04-11",
        "last_updated": "2024-08-28",
        "certification_date": "2024-08-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223S0112X",
            "taxonomy_group": "",
            "desc": "Dentist, Oral and Maxillofacial Surgery",
            "state": "NJ",
            "license": "22DI03026500",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Oral and Maxillofacial Surgery (Dentist) in Westwood, NJ
• Providers in Westwood, NJ by specialty
• Oral and Maxillofacial Surgery (Dentist) in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 28, 2024; 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.