Healthcare Provider Details

I. General information

NPI: 1295118040
Provider Name (Legal Business Name): CHRISTY MINTER BOUDREAUX D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 LEE ST
LUMBERTON TX
77657-7577
US

IV. Provider business mailing address

175 LEE ST
LUMBERTON TX
77657-7577
US

V. Phone/Fax

Practice location:
  • Phone: 409-755-6565
  • Fax: 409-755-3718
Mailing address:
  • Phone: 409-755-6565
  • Fax: 409-755-3718

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number31110
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: