Provider Demographics
NPI:1053961276
Name:BOULOS, RAFIK
Entity type:Individual
Prefix:
First Name:RAFIK
Middle Name:
Last Name:BOULOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3730 LIGON RD
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-5241
Mailing Address - Country:US
Mailing Address - Phone:410-900-3882
Mailing Address - Fax:
Practice Address - Street 1:8501 LASALLE RD
Practice Address - Street 2:306
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-296-7599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD170851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice