Healthcare Provider Details

I. General information

NPI: 1073757910
Provider Name (Legal Business Name): BRIAN LEE BOUCK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 04/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 E SAN MARNAN DR
WATERLOO IA
50702-5837
US

IV. Provider business mailing address

315 E SAN MARNAN DR
WATERLOO IA
50702-5837
US

V. Phone/Fax

Practice location:
  • Phone: 319-235-6287
  • Fax:
Mailing address:
  • Phone: 319-235-6287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6490
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: