Provider Demographics
NPI:1053331769
Name:BOUGHER, MARCEL T (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCEL
Middle Name:T
Last Name:BOUGHER
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 1:9950 CAMPO RD
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-1629
Mailing Address - Country:US
Mailing Address - Phone:619-463-2097
Mailing Address - Fax:619-463-2521
Practice Address - Street 1:9950 CAMPO RD
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91977-1629
Practice Address - Country:US
Practice Address - Phone:619-463-2097
Practice Address - Fax:619-463-2521
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice