Provider Demographics
NPI:1083793210
Name:BOUCHER, MARIE CHRISTINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:CHRISTINE
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516
Mailing Address - Country:US
Mailing Address - Phone:203-937-7181
Mailing Address - Fax:203-937-1940
Practice Address - Street 1:10 HIGGINS HIGHWAY
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06250
Practice Address - Country:US
Practice Address - Phone:860-423-2587
Practice Address - Fax:203-239-5648
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT93031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008002392Medicaid
CT008002392Medicaid
CT190000978Medicare ID - Type Unspecified