Provider Demographics
NPI:1316786148
Name:BOUCHARD, BRYAN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:BOUCHARD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:592 MUDGETT RD
Mailing Address - Street 2:
Mailing Address - City:LEVANT
Mailing Address - State:ME
Mailing Address - Zip Code:04456-4146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 MOUNT HOPE AVE STE 610
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5673
Practice Address - Country:US
Practice Address - Phone:207-945-5952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-21
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN51401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice