Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 4139 | MD |
N | 1223S0112X | Oral and Maxillofacial Surgeon | DEN2333 | DC |
NPI | 1063532059 |
---|---|
Provider Name | Dr. Stanley A Boucree SR. |
First Address | Silver Spring, MD 20910-2816 |
Second Address | Silver Spring, MD 20910-2816 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2007 |
Last Update Date | 27/12/2021 |