Provider Demographics
NPI:1629131156
Name:BOUSSELOT, DENNIS C (RPH)
Entity Type:Individual
Prefix:MR
First Name:DENNIS
Middle Name:C
Last Name:BOUSSELOT
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2433 259TH AVE
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:IA
Mailing Address - Zip Code:52742
Mailing Address - Country:US
Mailing Address - Phone:563-659-9804
Mailing Address - Fax:
Practice Address - Street 1:629 6TH AVE
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:IA
Practice Address - Zip Code:52742
Practice Address - Country:US
Practice Address - Phone:563-659-5042
Practice Address - Fax:563-659-5044
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA14363183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist