Healthcare Provider Details

I. General information

NPI: 1114183126
Provider Name (Legal Business Name): LIBERTY ANN BOUCHER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 UNIVERSITY AVE
MADISON WI
53705-2137
US

IV. Provider business mailing address

3320 UNIVERSITY AVE
MADISON WI
53705-2137
US

V. Phone/Fax

Practice location:
  • Phone: 608-238-8228
  • Fax:
Mailing address:
  • Phone: 608-238-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6297-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: