Provider Demographics
NPI:1942404793
Name:ROUSSEL, MARTHA VANDERSYPEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:VANDERSYPEN
Last Name:ROUSSEL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39450 QUAIL CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:PRAIRIEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70769-4829
Mailing Address - Country:US
Mailing Address - Phone:225-603-0590
Mailing Address - Fax:
Practice Address - Street 1:8220 GOODWOOD BLVD STE 4B
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7741
Practice Address - Country:US
Practice Address - Phone:225-603-0590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist