Carly Rachelle Boudreaux, DMD

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

2021024201 Issued in MO

Practice address

1709 Heritage Hills Dr
Washington, MO 63090-4621

Phone

(636) 238-3520

NPI assigned

May 14, 2019

Last updated

Aug 5, 2021By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• University Pediatric Dentistry Associates

  • Pediatric Dentistry
  • Indianapolis, IN
  • NPI 1003947599
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1557792000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1628121600000",
    "number": "1326604497",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "114 METALS DR",
            "city": "YOUNGSVILLE",
            "state": "LA",
            "postal_code": "705925812",
            "telephone_number": "337-654-6866"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1709 HERITAGE HILLS DR",
            "city": "WASHINGTON",
            "state": "MO",
            "postal_code": "630904621",
            "telephone_number": "636-238-3520"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BOUDREAUX",
        "first_name": "CARLY",
        "middle_name": "RACHELLE",
        "name_prefix": "Dr.",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2019-05-14",
        "last_updated": "2021-08-05",
        "certification_date": "2021-08-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "MO",
            "license": "2021024201",
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Christina Marie Blankenship, NP
• Carl F Blatt Jr., M.D.
• Christy R Bleckman, M.D.
• Bloom Behavior Services LLC
• Meghan Boland, MS, CCC-SLP
• Julie Bourne
• Corynn Boyer, OTR/L, OTD
• Tyler E Boyet, D.O.
• Brad McMillin, Inc (Beltone Hearing Aid Service)
• Ashley Nicole Brandt

• Pediatric Dentistry in Washington, MO
• Providers in Washington, MO by specialty
• Pediatric Dentistry in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.