MEDICARE: DR. ROBERT D ROUSSEAU DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	13502	MI

General Provider Information

NPI Number	:	1225250319
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT D ROUSSEAU DDS

Provider Business Mailing Address
First Line	:	6405 TELEGRAPH RD STE J-3
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-1775
Country	:	US
Telephone Number	:	248-642-5460
Fax Number	:	248-642-5471

Provider Business Practice Location Address
First Line	:	6405 TELEGRAPH RD STE J-3
Second Line	:
City	:	BLOOMFIELD HILLS
State	:	MI
Zip	:	48301-1775
Country	:	US
Telephone Number	:	248-642-5460
Fax Number	:	248-642-5471

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	07/08/2007

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