Provider Demographics
NPI:1326604497
Name:BOUDREAUX, CARLY RACHELLE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:RACHELLE
Last Name:BOUDREAUX
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 METALS DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70592-5812
Mailing Address - Country:US
Mailing Address - Phone:337-654-6866
Mailing Address - Fax:
Practice Address - Street 1:1709 HERITAGE HILLS DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-4621
Practice Address - Country:US
Practice Address - Phone:636-238-3520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO20210242011223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program