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General NPI Number Information
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NPI Number | 1619280781
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Entity Type | Organization
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Legal Business Name | JOEL E. BROUSSARD JR. D.D.S.,M.S. INC.
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Dates
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Enumeration Date | 07/19/2010
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 11149 RESEARCH BLVD STE 270
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City | AUSTIN
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State | TX
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Zip | 78759-5227
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Country | US
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Telephone | 512-346-1221
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Fax | 512-502-9689
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Provider Business Mailing Address
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Address Line | 11149 RESEARCH BLVD STE 270
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City | AUSTIN
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State | TX
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Zip | 78759-5227
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Country | US
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Telephone | 512-346-1221
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Fax | 512-502-9689
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOEL E BROUSSARD JR.
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Credential | D.D.S.,M.S.
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Telephone | 512-346-1221
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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 | 8751
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License Number State | TX
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