Healthcare Provider Details

I. General information

NPI: 1952374035
Provider Name (Legal Business Name): JOHN S. BROUSSEAU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KARLSRUHERSTR 144 US ARMY HOSPITAL DENTAL CLINIC/BLDG 3613
HEIDELBERG BADEN WURTEMBOURG
69126
DE

IV. Provider business mailing address

IN DER BOHN 18
WIESLOCH BADEN WURTEMBOURG
69168
DE

V. Phone/Fax

Practice location:
  • Phone: 06221172728
  • Fax:
Mailing address:
  • Phone: 06222385304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number17691
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: