Provider Demographics
NPI:1114183126
Name:BOUCHER, LIBERTY ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:LIBERTY
Middle Name:ANN
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 1:4037 N DOWNER AVE
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-2127
Mailing Address - Country:US
Mailing Address - Phone:414-418-2280
Mailing Address - Fax:
Practice Address - Street 1:7040 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3838
Practice Address - Country:US
Practice Address - Phone:414-351-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6297-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice