Provider Demographics
NPI:1710242193
Name:BOLOURI, MITRA FATIMA (DDS)
Entity type:Individual
Prefix:DR
First Name:MITRA
Middle Name:FATIMA
Last Name:BOLOURI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8355 WALNUT HILL LN STE 130
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75231-4240
Mailing Address - Country:US
Mailing Address - Phone:214-361-2208
Mailing Address - Fax:
Practice Address - Street 1:8355 WALNUT HILL LN STE 130
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4240
Practice Address - Country:US
Practice Address - Phone:214-361-2208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX280051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice