Nardeen Boulos, DMD

Key facts

NPI

1679190342

Entity type

Individual (NPI type 1)

Primary specialty

Dentist 122300000X

License

104954 (CA)

Practice address

1695 S San Jacinto Ave Ste N
San Jacinto, CA 92583-5104

Phone

(949) 521-9854

NPI assigned

Jun 29, 2020

Sex

Female

Sole proprietor

No

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

State licenses

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Jan 10, 2024.

{
    "created_epoch": "1593388800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1704844800000",
    "number": "1679190342",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "78 BILLINGS AVE",
            "city": "BEAUMONT",
            "state": "CA",
            "postal_code": "922233127",
            "telephone_number": "949-521-9854"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1695 S SAN JACINTO AVE STE N",
            "city": "SAN JACINTO",
            "state": "CA",
            "postal_code": "925835104",
            "telephone_number": "949-521-9854"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOULOS",
        "first_name": "NARDEEN",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2020-06-29",
        "last_updated": "2024-01-10",
        "certification_date": "2024-01-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "CA",
            "license": "104954",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in San Jacinto, CA · Dentist in California