Provider Demographics
NPI:1467597435
Name:THIBODEAUX, ANDREW J (DDS)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:J
Last Name:THIBODEAUX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-1326
Mailing Address - Country:US
Mailing Address - Phone:818-365-4525
Mailing Address - Fax:818-365-4506
Practice Address - Street 1:1058 N MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-1326
Practice Address - Country:US
Practice Address - Phone:818-365-4525
Practice Address - Fax:818-365-4506
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice