MEDICARE: BRYAN C BOUCHELION DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	021002012	IL

General Provider Information

NPI Number	:	1801966478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN C BOUCHELION DDS

Provider Business Mailing Address
First Line	:	10713 W 159TH ST
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60467-4531
Country	:	US
Telephone Number	:	708-301-5000
Fax Number	:	708-403-8966

Provider Business Practice Location Address
First Line	:	10713 W 159TH ST
Second Line	:
City	:	ORLAND PARK
State	:	IL
Zip	:	60467
Country	:	US
Telephone Number	:	708-301-5000
Fax Number	:	708-403-8966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2006
Last Update Date	:	05/22/2026

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