Active NPI
Tammy Marie Boudry, DDS
- Dentist
- Fond Du Lac, WI
National Provider Identifier
1548489966
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 6050 - 15
- Practice address
- 133 Parkway CT
Fond Du Lac, WI 54935-3809 - Phone
- (920) 921-0158
- NPI assigned
- Apr 24, 2007
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 6050 - 15 | WI | Primary |
Addresses
Primary practice location
133 Parkway CT
Fond Du Lac, WI 54935-3809
Mailing address
PO Box 1323
Fond Du Lac, WI 54936-1323
Phone (920) 921-0158
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in WI
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20151125000525 | WI | Order and Referring Only - Oral Surgery | 5395045264 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 6050 - 15 | WI | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1177372800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1548489966",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1323",
"city": "FOND DU LAC",
"state": "WI",
"postal_code": "549361323",
"telephone_number": "920-921-0158"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "133 PARKWAY CT",
"city": "FOND DU LAC",
"state": "WI",
"postal_code": "549353809",
"telephone_number": "920-921-0158"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BOUDRY",
"first_name": "TAMMY",
"middle_name": "MARIE",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2007-04-24",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "WI",
"license": "6050 - 15",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fond Du Lac, WI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; 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.