Provider Demographics
NPI:1215627724
Name:BOUCHARD, BENJAMIN (DDS)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3989 CASCADE RD SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2178
Mailing Address - Country:US
Mailing Address - Phone:616-459-7171
Mailing Address - Fax:616-459-7181
Practice Address - Street 1:3989 CASCADE RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2178
Practice Address - Country:US
Practice Address - Phone:616-459-7171
Practice Address - Fax:616-459-7181
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901602468122300000X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist