=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033778246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEX BOUCHER DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 309 SAINT THOMAS ST STE 213
-----------------------------------------------------
City | MADAWASKA
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04756-1278
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-728-3971
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 88 ST JOHN RD
-----------------------------------------------------
City | FORT KENT
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04743-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-521-4985
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DEN4730
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------