Provider Demographics
NPI:1649287301
Name:ROULEAU, BERT D (DMD MS)
Entity type:Individual
Prefix:DR
First Name:BERT
Middle Name:D
Last Name:ROULEAU
Suffix:
Gender:M
Credentials:DMD MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1174 CASTRO ST
Mailing Address - Street 2:# 120
Mailing Address - City:MT VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040
Mailing Address - Country:US
Mailing Address - Phone:650-964-6400
Mailing Address - Fax:650-964-0797
Practice Address - Street 1:1174 CASTRO ST
Practice Address - Street 2:# 120
Practice Address - City:MT VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040
Practice Address - Country:US
Practice Address - Phone:650-964-6400
Practice Address - Fax:650-964-0797
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA298681223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics