Provider Demographics
NPI:1508040445
Name:BOUCHARD, PATRICIA L
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 LARKSPUR LN
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-8937
Mailing Address - Country:US
Mailing Address - Phone:860-585-0462
Mailing Address - Fax:
Practice Address - Street 1:157 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6427
Practice Address - Country:US
Practice Address - Phone:860-489-1328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005714124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist