Provider Demographics
NPI:1720694466
Name:ROUCHON DENTAL
Entity Type:Organization
Organization Name:ROUCHON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIPPE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:ROUCHON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:646-596-6443
Mailing Address - Street 1:1810 CALIFORNIA ST NW APT 105
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20009-1825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3930 KNOWLES AVE STE 302
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:MD
Practice Address - Zip Code:20895-2428
Practice Address - Country:US
Practice Address - Phone:240-669-4684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740595545Medicaid