MEDICARE: DR. MICHAEL E ROUSSEL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	1422DD	NM

General Provider Information

NPI Number	:	1578670774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL E ROUSSEL DMD

Provider Business Mailing Address
First Line	:	7127 PROSPECT PL NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4313
Country	:	US
Telephone Number	:	505-881-4365
Fax Number	:	505-881-8282

Provider Business Practice Location Address
First Line	:	7127 PROSPECT PL NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4313
Country	:	US
Telephone Number	:	505-881-4365
Fax Number	:	505-881-8282

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	06/30/2015

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