Provider Demographics
NPI:1669562948
Name:BERUBE, ILSE WERNER (DMD)
Entity type:Individual
Prefix:DR
First Name:ILSE
Middle Name:WERNER
Last Name:BERUBE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1937 CENTRAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-4205
Mailing Address - Country:US
Mailing Address - Phone:321-723-0671
Mailing Address - Fax:321-723-4454
Practice Address - Street 1:1937 CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4205
Practice Address - Country:US
Practice Address - Phone:321-723-0671
Practice Address - Fax:321-723-4454
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN14259122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist