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General NPI Number Information
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NPI Number | 1033313689
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Entity Type | Organization
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Legal Business Name | MARTHA V. ROUSSEL, DDS, LLC
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 06/16/2008
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Provider Practice Location Address
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Address Line | 8220 GOODWOOD BLVD STE 4B
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City | BATON ROUGE
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State | LA
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Zip | 70806-7741
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Country | US
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Telephone | 225-603-0590
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Fax |
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Provider Business Mailing Address
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Address Line | 39450 QUAIL CREEK AVE
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City | PRAIRIEVILLE
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State | LA
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Zip | 70769-4829
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Country | US
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Telephone | 225-603-0590
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. MARTHA VANDERSYPEN ROUSSEL
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Credential | DDS
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Telephone | 225-603-0590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 5276
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License Number State | LA
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