Provider Demographics
NPI:1467801506
Name:BORDELON, AMY (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:BORDELON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 KERR ST STE 104
Mailing Address - Street 2:
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-7803
Mailing Address - Country:US
Mailing Address - Phone:337-942-3221
Mailing Address - Fax:
Practice Address - Street 1:1604 KERR ST STE 104
Practice Address - Street 2:
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-7803
Practice Address - Country:US
Practice Address - Phone:337-942-3221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6666122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist