Basic Information
| Provider Information | |||||||||
| NPI: | 1073009767 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUTEHSAZ | ||||||||
| FirstName: | ARMIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2221 E BIJOU ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809098009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195761850 | ||||||||
| FaxNumber: | 7199553470 | ||||||||
| Practice Location | |||||||||
| Address1: | 1253 W PRATT ST | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212232684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107274746 | ||||||||
| FaxNumber: | 4107276767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2018 | ||||||||
| LastUpdateDate: | 09/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 16564 | MD | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 767008700 | 05 | MD | MEDICAID | 965375292 | 01 | ADA | OTHER |