Provider Demographics
NPI:1083783302
Name:BROUSSARD, MARK A (DDS)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:BROUSSARD
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 NORTH AVENUE K
Mailing Address - Street 2:
Mailing Address - City:CROWLEY
Mailing Address - State:LA
Mailing Address - Zip Code:70526
Mailing Address - Country:US
Mailing Address - Phone:337-788-0677
Mailing Address - Fax:337-783-0343
Practice Address - Street 1:608 NORTH AVENUE K
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526
Practice Address - Country:US
Practice Address - Phone:337-788-0677
Practice Address - Fax:337-783-0343
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA49051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice