Provider Demographics
NPI:1205215506
Name:MICHAEL E ROUSSEL DMD PC
Entity Type:Organization
Organization Name:MICHAEL E ROUSSEL DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:ROUSSEL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-881-4365
Mailing Address - Street 1:7127 PROSPECT PL NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4313
Mailing Address - Country:US
Mailing Address - Phone:505-881-4365
Mailing Address - Fax:505-881-8282
Practice Address - Street 1:7127 PROSPECT PL NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4313
Practice Address - Country:US
Practice Address - Phone:505-881-4365
Practice Address - Fax:505-881-8282
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1422122300000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty