Provider Demographics
NPI:1659510675
Name:BOUDREAUX, LEROY JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:JOSEPH
Last Name:BOUDREAUX
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 1:209 IBERVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-2419
Mailing Address - Country:US
Mailing Address - Phone:225-473-9808
Mailing Address - Fax:225-473-3701
Practice Address - Street 1:209 IBERVILLE ST
Practice Address - Street 2:
Practice Address - City:DONALDSONVILLE
Practice Address - State:LA
Practice Address - Zip Code:70346-2419
Practice Address - Country:US
Practice Address - Phone:225-473-9808
Practice Address - Fax:225-473-3701
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-14
Last Update Date:2009-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA22671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice