Healthcare Provider Details

I. General information

NPI: 1144370818
Provider Name (Legal Business Name): MANON BOURQUE HUTCHISON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5359 LYONS RD
COCONUT CREEK FL
33073-2825
US

IV. Provider business mailing address

5359 LYONS RD
COCONUT CREEK FL
33073-2825
US

V. Phone/Fax

Practice location:
  • Phone: 954-570-8870
  • Fax: 954-571-6136
Mailing address:
  • Phone: 954-570-8870
  • Fax: 954-571-6136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 0013436
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: