Provider Demographics
NPI:1356773691
Name:BOUCHER, SHELLI (DMD)
Entity type:Individual
Prefix:DR
First Name:SHELLI
Middle Name:
Last Name:BOUCHER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 MARRON DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-4510
Mailing Address - Country:US
Mailing Address - Phone:860-428-7204
Mailing Address - Fax:
Practice Address - Street 1:185 MARRON DR
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-4510
Practice Address - Country:US
Practice Address - Phone:860-428-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC115381223G0001X
VA04420001921223G0001X
SC88711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice