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General NPI Number Information
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NPI Number | 1326604497
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Entity Type | Individual
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Provider Name | CARLY RACHELLE BOUDREAUX DMD
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Gender | Female
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Dates
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Enumeration Date | 05/14/2019
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Last Update Date | 08/05/2021
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Provider Practice Location Address
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Address Line | 1709 HERITAGE HILLS DR
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City | WASHINGTON
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State | MO
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Zip | 63090-4621
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Country | US
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Telephone | 636-238-3520
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Fax |
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Provider Business Mailing Address
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Address Line | 114 METALS DR
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City | YOUNGSVILLE
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State | LA
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Zip | 70592-5812
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Country | US
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Telephone | 337-654-6866
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 2021024201
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License Number State | MO
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