Provider Demographics
NPI:1205146248
Name:MICHAEL G. BROUTSAS D.D.S.,P.C.
Entity type:Organization
Organization Name:MICHAEL G. BROUTSAS D.D.S.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROUTSAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:508-824-7023
Mailing Address - Street 1:54 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-4228
Mailing Address - Country:US
Mailing Address - Phone:508-824-7023
Mailing Address - Fax:823-075-7508
Practice Address - Street 1:54 WINTHROP ST
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-4228
Practice Address - Country:US
Practice Address - Phone:508-824-7023
Practice Address - Fax:823-075-7508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-08
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA121591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX03787Medicare PIN