=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346349818
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | APPLETON DENTAL ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2006
-----------------------------------------------------
Last Update Date | 01/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 PINEHURST ROAD
-----------------------------------------------------
City | HOLYOKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-534-4033
-----------------------------------------------------
Fax | 413-532-5509
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 PINEHURST ROAD
-----------------------------------------------------
City | HOLYOKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-534-4033
-----------------------------------------------------
Fax | 413-532-5509
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT OWNER
-----------------------------------------------------
Name | DR. ANDRE DONALD ROUSSEAU
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 413-534-4033
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 16531
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------