Provider Demographics
NPI:1477885101
Name:DR. EUGENE D. ROUSH, SC
Entity Type:Organization
Organization Name:DR. EUGENE D. ROUSH, SC
Other - Org Name:BIRCH POINT DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTISIT/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:ROUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:715-945-2901
Mailing Address - Street 1:PO BOX 8
Mailing Address - Street 2:
Mailing Address - City:RADISSON
Mailing Address - State:WI
Mailing Address - Zip Code:54867-0008
Mailing Address - Country:US
Mailing Address - Phone:715-945-2901
Mailing Address - Fax:715-945-2805
Practice Address - Street 1:3661 N HIGHLAND DRIVE
Practice Address - Street 2:
Practice Address - City:RADISSON
Practice Address - State:WI
Practice Address - Zip Code:54867
Practice Address - Country:US
Practice Address - Phone:715-945-2901
Practice Address - Fax:715-945-2805
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2853122300000X
WI5072122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty