Provider Demographics
NPI:1265523633
Name:BERUBE, ANDRE JEAN (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:JEAN
Last Name:BERUBE
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 1:5240 BABCOCK ST NE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32905
Mailing Address - Country:US
Mailing Address - Phone:321-722-2193
Mailing Address - Fax:321-953-2888
Practice Address - Street 1:5240 BABCOCK ST NE
Practice Address - Street 2:SUITE 205
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905
Practice Address - Country:US
Practice Address - Phone:321-722-2193
Practice Address - Fax:321-953-2888
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00112211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice