Provider Demographics
NPI:1245320761
Name:BOUDREAU, JAMES ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ROBERT
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13334 MINNIEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-4033
Mailing Address - Country:US
Mailing Address - Phone:703-910-3285
Mailing Address - Fax:703-670-0351
Practice Address - Street 1:13334 MINNIEVILLE RD
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-4033
Practice Address - Country:US
Practice Address - Phone:703-910-3285
Practice Address - Fax:703-670-0351
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014135021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice