Provider Demographics
NPI:1154635530
Name:BROUSSEAU, KEVIN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:M
Last Name:BROUSSEAU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 EMORY ST
Mailing Address - Street 2:
Mailing Address - City:ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02703-2461
Mailing Address - Country:US
Mailing Address - Phone:508-222-8838
Mailing Address - Fax:508-226-8157
Practice Address - Street 1:152 EMORY ST
Practice Address - Street 2:
Practice Address - City:ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02703-2461
Practice Address - Country:US
Practice Address - Phone:508-222-8838
Practice Address - Fax:508-226-8157
Is Sole Proprietor?:No
Enumeration Date:2010-07-28
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA171501223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice