Provider Demographics
NPI:1942800586
Name:BOULOS, MAHA M (DDS)
Entity type:Individual
Prefix:DR
First Name:MAHA
Middle Name:M
Last Name:BOULOS
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 1:23332 HAWTHORNE BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-3766
Mailing Address - Country:US
Mailing Address - Phone:310-792-0049
Mailing Address - Fax:
Practice Address - Street 1:23332 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-3749
Practice Address - Country:US
Practice Address - Phone:206-229-3854
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2020-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice