Provider Demographics
NPI:1033313689
Name:MARTHA V. ROUSSEL, DDS, LLC
Entity Type:Organization
Organization Name:MARTHA V. ROUSSEL, DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:VANDERSYPEN
Authorized Official - Last Name:ROUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:225-603-0590
Mailing Address - Street 1:39450 QUAIL CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4829
Mailing Address - Country:US
Mailing Address - Phone:225-603-0590
Mailing Address - Fax:
Practice Address - Street 1:8220 GOODWOOD BLVD STE 4B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7741
Practice Address - Country:US
Practice Address - Phone:225-603-0590
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty