Provider Demographics
NPI:1154550135
Name:BOUDREAUX, GARY LAMON (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:LAMON
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 1:8815 DYER ST STE 255
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79904-2033
Mailing Address - Country:US
Mailing Address - Phone:915-757-2688
Mailing Address - Fax:915-757-2689
Practice Address - Street 1:8815 DYER ST STE 255
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79904-2033
Practice Address - Country:US
Practice Address - Phone:915-757-2688
Practice Address - Fax:915-757-2689
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2009-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice