Healthcare Provider Details

I. General information

NPI: 1003952334
Provider Name (Legal Business Name): RICHARD GEORGE BOUDREAU D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13160 MINDANAO WAY SUITE 120
MARINA DEL REY CA
90292-6358
US

IV. Provider business mailing address

13160 MINDANAO WAY SUITE 120
MARINA DEL REY CA
90292-6358
US

V. Phone/Fax

Practice location:
  • Phone: 310-822-6161
  • Fax: 310-822-6825
Mailing address:
  • Phone: 310-822-6161
  • Fax: 310-822-6825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD21852
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: