Provider Demographics
NPI:1821093832
Name:BROUSSARD, JACK S JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:S
Last Name:BROUSSARD
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S FAIR OAKS AVE
Mailing Address - Street 2:STE 204
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-2536
Mailing Address - Country:US
Mailing Address - Phone:626-796-3161
Mailing Address - Fax:626-796-6760
Practice Address - Street 1:301 S FAIR OAKS AVE
Practice Address - Street 2:STE 204
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2536
Practice Address - Country:US
Practice Address - Phone:626-796-3161
Practice Address - Fax:626-796-6760
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADN260401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice