MEDICARE: MS. KIMBERLY BOUDREAUX RDH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	124Q00000X	Dental Hygienist	6369-016	WI

General Provider Information

NPI Number	:	1124385406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KIMBERLY BOUDREAUX RDH

Provider Business Mailing Address
First Line	:	5559 DEERFIELD RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-1819
Country	:	US
Telephone Number	:	262-770-1824
Fax Number	:

Provider Business Practice Location Address
First Line	:	5559 DEERFIELD RD
Second Line	:
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-1819
Country	:	US
Telephone Number	:	262-770-1824
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2012
Last Update Date	:	04/11/2012

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