Provider Demographics
NPI:1548342413
Name:BOUCHARD, NANCY ELLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:ELLEN
Last Name:BOUCHARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7130 ESTERO BLVD
Mailing Address - Street 2:UNIT #2
Mailing Address - City:FORT MYERS BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33931
Mailing Address - Country:US
Mailing Address - Phone:239-463-5433
Mailing Address - Fax:
Practice Address - Street 1:7130 ESTERO BLVD
Practice Address - Street 2:UNIT #2
Practice Address - City:FORT MYERS BEACH
Practice Address - State:FL
Practice Address - Zip Code:33931
Practice Address - Country:US
Practice Address - Phone:239-463-5433
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD137531223G0001X
FL214271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice