Provider Demographics
NPI:1184693723
Name:ROUSE, PAUL J (DMD)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:ROUSE
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 1:544 MAGNOLIA DR N
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-3236
Mailing Address - Country:US
Mailing Address - Phone:601-928-5711
Mailing Address - Fax:601-928-7712
Practice Address - Street 1:15024 MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501
Practice Address - Country:US
Practice Address - Phone:228-863-9781
Practice Address - Fax:228-864-8553
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS179077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0060456Medicaid