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General NPI Number Information
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NPI Number | 1225179047
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Entity Type | Organization
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Legal Business Name | BERT D. ROULEAU D.M.D, M.S. INK
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Dates
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Enumeration Date | 02/12/2007
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1174 CASTRO ST STE 120
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City | MOUNTAIN VIEW
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State | CA
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Zip | 94040-2569
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Country | US
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Telephone | 650-964-6400
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Fax | 650-964-0797
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Provider Business Mailing Address
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Address Line | 1174 CASTRO ST STE 120
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City | MOUNTAIN VIEW
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State | CA
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Zip | 94040-2569
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Country | US
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Telephone | 650-964-6400
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Fax | 650-964-0797
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Authorized Official
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Title or Position | RDA
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Name | GABRIELA A MARTINEZ
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Credential |
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Telephone | 650-964-6400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State | CA
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