Provider Demographics
NPI:1215596556
Name:BROUSSARD, MORGAN ELIZABETH (DDS)
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:ELIZABETH
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MARKET CENTER DR STE 102
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-7077
Mailing Address - Country:US
Mailing Address - Phone:901-850-7338
Mailing Address - Fax:
Practice Address - Street 1:60 MARKET CENTER DR STE 102
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-7077
Practice Address - Country:US
Practice Address - Phone:901-850-7338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN110721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice