Healthcare Provider Details

I. General information

NPI: 1225179047
Provider Name (Legal Business Name): BERT D. ROULEAU D.M.D, M.S. INK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 CASTRO ST STE 120
MOUNTAIN VIEW CA
94040-2569
US

IV. Provider business mailing address

1174 CASTRO ST STE 120
MOUNTAIN VIEW CA
94040-2569
US

V. Phone/Fax

Practice location:
  • Phone: 650-964-6400
  • Fax: 650-964-0797
Mailing address:
  • Phone: 650-964-6400
  • Fax: 650-964-0797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateCA

VIII. Authorized Official

Name: GABRIELA A MARTINEZ
Title or Position: RDA
Credential:
Phone: 650-964-6400