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General NPI Number Information
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NPI Number | 1265151112
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Entity Type | Individual
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Provider Name | CHLOE BOUCHER
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Gender | Female
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Dates
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Enumeration Date | 08/24/2022
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Last Update Date | 10/01/2025
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Provider Practice Location Address
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Address Line | 3990 SAN JOSE PARK DR
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City | JACKSONVILLE
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State | FL
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Zip | 32217-4613
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Country | US
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Telephone | 904-731-1324
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Fax |
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Provider Business Mailing Address
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Address Line | 1 RIVERSIDE AVE APT 3520
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City | JACKSONVILLE
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State | FL
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Zip | 32202-5156
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Country | US
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Telephone | 514-942-7440
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | DN28865
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License Number State | FL
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