Provider Demographics
NPI:1669743498
Name:RAYFUS J BROUSSARD, DDS INC
Entity type:Organization
Organization Name:RAYFUS J BROUSSARD, DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYFUS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BROUSSARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:409-898-7847
Mailing Address - Street 1:1120 LONGFELLOW DR
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77706-4845
Mailing Address - Country:US
Mailing Address - Phone:409-898-7847
Mailing Address - Fax:
Practice Address - Street 1:1120 LONGFELLOW DR
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-4845
Practice Address - Country:US
Practice Address - Phone:409-898-7847
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX114071223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164122701Medicaid