Healthcare Provider Details

I. General information

NPI: 1083346753
Provider Name (Legal Business Name): BOUCHER FAMILY DENTISTRY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2022
Last Update Date: 06/30/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 LOVELL ST
IONIA MI
48846-9706
US

IV. Provider business mailing address

PO BOX 118
IONIA MI
48846-0118
US

V. Phone/Fax

Practice location:
  • Phone: 616-527-3050
  • Fax: 616-527-3667
Mailing address:
  • Phone: 616-527-3050
  • Fax: 616-527-3667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AARON BOUCHER
Title or Position: OWNER
Credential:
Phone: 616-527-3050