Healthcare Provider Details

I. General information

NPI: 1700806775
Provider Name (Legal Business Name): DONALD PAUL BOUDREAUX JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 RUE DE BRILLE
NEW IBERIA LA
70563-2122
US

IV. Provider business mailing address

606 RUE DE BRILLE
NEW IBERIA LA
70563-2122
US

V. Phone/Fax

Practice location:
  • Phone: 337-560-0131
  • Fax:
Mailing address:
  • Phone: 337-560-0131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5387
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: