Provider Demographics
NPI:1013927037
Name:BROUTIN, OLIVIER (DMD)
Entity Type:Individual
Prefix:DR
First Name:OLIVIER
Middle Name:
Last Name:BROUTIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4400 E HIGHWAY 20
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-8779
Mailing Address - Country:US
Mailing Address - Phone:850-897-4488
Mailing Address - Fax:850-897-1446
Practice Address - Street 1:4400 E HIGHWAY 20
Practice Address - Street 2:SUITE 101
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-8779
Practice Address - Country:US
Practice Address - Phone:850-897-4488
Practice Address - Fax:850-897-1446
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15111122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist