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General NPI Number Information
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NPI Number | 1669743498
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Entity Type | Organization
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Legal Business Name | RAYFUS J BROUSSARD, DDS INC
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Dates
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Enumeration Date | 01/25/2012
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Last Update Date | 01/25/2012
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Provider Practice Location Address
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Address Line | 1120 LONGFELLOW DR
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City | BEAUMONT
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State | TX
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Zip | 77706-4845
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Country | US
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Telephone | 409-898-7847
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Fax |
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Provider Business Mailing Address
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Address Line | 1120 LONGFELLOW DR
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City | BEAUMONT
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State | TX
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Zip | 77706-4845
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Country | US
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Telephone | 409-898-7847
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Fax |
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Authorized Official
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Title or Position | ORTHODONTIST
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Name | DR. RAYFUS J BROUSSARD
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Credential | D.D.S.
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Telephone | 409-898-7847
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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 | 11407
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License Number State | TX
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