1639391550 NPI number — DR. SOULAFA SUSAN BALOUL DMD, MS, DSCD

Table of content: DR. SOULAFA SUSAN BALOUL DMD, MS, DSCD (NPI 1639391550)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639391550 NPI number — DR. SOULAFA SUSAN BALOUL DMD, MS, DSCD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BALOUL
Provider First Name:
SOULAFA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD, MS, DSCD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BALOUL
Provider Other First Name:
SOULAFA
Provider Other Middle Name:
SUSAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DMD
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1639391550
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 CENTRAL ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWOOD
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02062-3504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-769-8000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
177 TREMONT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOSTON
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02111-1020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
617-617-7677
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/02/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223X0400X , with the licence number:  27643 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X , with the licence number: DN20656 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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