Carlos Bou Assi, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

22DI02299200 Issued in NJ

Practice address

10590 Enduring Freedom Drive
Fort Drum, NY 13602-5005

Phone

(315) 772-6234

Fax

(315) 774-3558

NPI assigned

Sep 21, 2006

Last updated

Apr 9, 2015By the provider in NPPES

Sex

Male

Sole proprietor

No

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

Specialties & licenses 3

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

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

{
    "created_epoch": "1158796800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1428537600000",
    "number": "1699874453",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10590 ENDURING FREEDOM DRIVE",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025005",
            "telephone_number": "315-772-6234",
            "fax_number": "315-774-3558"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10590 ENDURING FREEDOM DRIVE",
            "city": "FORT DRUM",
            "state": "NY",
            "postal_code": "136025005",
            "telephone_number": "315-772-6234",
            "fax_number": "315-774-3558"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOU ASSI",
        "first_name": "CARLOS",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-21",
        "last_updated": "2015-04-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NH",
            "license": "03622",
            "primary": false
        },
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "MA",
            "license": "21826",
            "primary": false
        },
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "NJ",
            "license": "22DI02299200",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jillisa Boller, DENTAL ASSISTANT X2
• Justine Noel Bolten, OTD, OTR/L
• Kyle Bolton
• Jessica Lynn Bondy-Carey, D.M.D.
• Don Bonham, LMSW, CASAC
• Kyle P Bourque, LISW
• Jane Bowers, R.D.H.
• Scott Michael Bowman, OTRL
• Jacqulin Suzanne Braner, PHARM.D.
• Holger Leonard Brencher, O.D., MS, BA

• General Practice Dentistry in Fort Drum, NY
• Providers in Fort Drum, NY by specialty
• General Practice Dentistry in New York

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 9, 2015; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.