Provider Demographics
NPI:1245793108
Name:BROUSSARD, CHERRY ANN (DDS)
Entity Type:Individual
Prefix:
First Name:CHERRY
Middle Name:ANN
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 1:2645 MANHATTAN BLVD STE D5
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-3386
Mailing Address - Country:US
Mailing Address - Phone:504-367-0355
Mailing Address - Fax:504-266-0021
Practice Address - Street 1:2645 MANHATTAN BLVD STE D5
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:LA
Practice Address - Zip Code:70058-3386
Practice Address - Country:US
Practice Address - Phone:504-367-0355
Practice Address - Fax:504-266-0021
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-08
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA69641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice