Provider Demographics
NPI:1447218953
Name:BOUDREAU, GEORGE E (DMD)
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:E
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 1:222 ELBOW LN
Mailing Address - Street 2:
Mailing Address - City:HAVERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:19041
Mailing Address - Country:US
Mailing Address - Phone:610-649-9837
Mailing Address - Fax:
Practice Address - Street 1:1740 SOUTH ST
Practice Address - Street 2:STE 504
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19146
Practice Address - Country:US
Practice Address - Phone:215-545-6334
Practice Address - Fax:215-893-4675
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS18682L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
T76254Medicare UPIN