1952374035 NPI number — DR. JOHN S. BROUSSEAU DDS

Table of content: DR. JOHN S. BROUSSEAU DDS (NPI 1952374035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952374035 NPI number — DR. JOHN S. BROUSSEAU DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSEAU
Provider First Name:
JOHN
Provider Middle Name:
S.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952374035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
IN DER BOHN 18
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WIESLOCH
Provider Business Mailing Address State Name:
BADEN WURTEMBOURG
Provider Business Mailing Address Postal Code:
69168
Provider Business Mailing Address Country Code:
DE
Provider Business Mailing Address Telephone Number:
06222385304
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KARLSRUHERSTR 144
Provider Second Line Business Practice Location Address:
US ARMY HOSPITAL DENTAL CLINIC/BLDG 3613
Provider Business Practice Location Address City Name:
HEIDELBERG
Provider Business Practice Location Address State Name:
BADEN WURTEMBOURG
Provider Business Practice Location Address Postal Code:
69126
Provider Business Practice Location Address Country Code:
DE
Provider Business Practice Location Address Telephone Number:
06221172728
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0700X , with the licence number:  17691 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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