Provider Demographics
NPI:1245550623
Name:ROUSSEAU, ANDRE DONALD (DDS)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:DONALD
Last Name:ROUSSEAU
Suffix:
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 1:101 PINEHURST RD
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01040-2217
Mailing Address - Country:US
Mailing Address - Phone:413-534-4033
Mailing Address - Fax:413-532-5509
Practice Address - Street 1:101 PINEHURST RD
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2217
Practice Address - Country:US
Practice Address - Phone:413-534-4033
Practice Address - Fax:413-532-5509
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA165311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice