Provider Demographics
NPI:1578670774
Name:ROUSSEL, MICHAEL E (DMD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:E
Last Name:ROUSSEL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:MIKE
Other - Middle Name:E
Other - Last Name:ROUSSEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
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
Is Sole Proprietor?:No
Enumeration Date:2006-08-24
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1422DD122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist