Provider Demographics
NPI:1184357386
Name:BOULOS, ANDREW MEENA (DMD)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:MEENA
Last Name:BOULOS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 FOLIAGE OAK TER
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32766-7022
Mailing Address - Country:US
Mailing Address - Phone:321-266-0811
Mailing Address - Fax:
Practice Address - Street 1:3411 SW 36TH TER UNIT 1
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7404
Practice Address - Country:US
Practice Address - Phone:352-390-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2022-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN27029122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist