Provider Demographics
NPI:1376686808
Name:ROUSSEAU, ROBERT T (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:T
Last Name:ROUSSEAU
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 1:40 FORREST LAKE DR NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-3311
Mailing Address - Country:US
Mailing Address - Phone:404-252-2450
Mailing Address - Fax:
Practice Address - Street 1:5555 PEACHTREE DUNWOODY RD NE STE 145
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1789
Practice Address - Country:US
Practice Address - Phone:404-255-7541
Practice Address - Fax:404-255-5829
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA108251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice