Provider Demographics
NPI:1952374035
Name:BROUSSEAU, JOHN S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:S
Last Name:BROUSSEAU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:IN DER BOHN 18
Mailing Address - Street 2:
Mailing Address - City:WIESLOCH
Mailing Address - State:BADEN WURTEMBOURG
Mailing Address - Zip Code:69168
Mailing Address - Country:DE
Mailing Address - Phone:0622-238-5304
Mailing Address - Fax:
Practice Address - Street 1:KARLSRUHERSTR 144
Practice Address - Street 2:US ARMY HOSPITAL DENTAL CLINIC/BLDG 3613
Practice Address - City:HEIDELBERG
Practice Address - State:BADEN WURTEMBOURG
Practice Address - Zip Code:69126
Practice Address - Country:DE
Practice Address - Phone:0622-117-2728
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX176911223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics