MEDICARE: DR. CARLY RACHELLE BOUDREAUX DMD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223P0221X	Pediatric Dentistry	2021024201	MO

General Provider Information

NPI Number	:	1326604497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CARLY RACHELLE BOUDREAUX DMD

Provider Business Mailing Address
First Line	:	114 METALS DR
Second Line	:
City	:	YOUNGSVILLE
State	:	LA
Zip	:	70592-5812
Country	:	US
Telephone Number	:	337-654-6866
Fax Number	:

Provider Business Practice Location Address
First Line	:	1709 HERITAGE HILLS DR
Second Line	:
City	:	WASHINGTON
State	:	MO
Zip	:	63090-4621
Country	:	US
Telephone Number	:	636-238-3520
Fax Number	:

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

Provider Enumeration Date	:	05/14/2019
Last Update Date	:	08/05/2021

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