Healthcare Provider Details

I. General information

NPI: 1952807380
Provider Name (Legal Business Name): SHAWN A BOUDREAUX
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12313 GREENVILLE HWY
LYMAN SC
29365-1515
US

IV. Provider business mailing address

218 THELMA DR
SUNSET LA
70584-5430
US

V. Phone/Fax

Practice location:
  • Phone: 864-439-3322
  • Fax:
Mailing address:
  • Phone: 337-308-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6841
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: