Provider Demographics
NPI:1942464417
Name:BOUCREE, THADDEUS STANICE (MD, DDS)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:STANICE
Last Name:BOUCREE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4224
Mailing Address - Country:US
Mailing Address - Phone:732-741-0970
Mailing Address - Fax:732-747-2606
Practice Address - Street 1:535 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:NJ
Practice Address - Zip Code:07702
Practice Address - Country:US
Practice Address - Phone:732-741-0970
Practice Address - Fax:732-747-2606
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA100830001223S0112X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery