Provider Demographics
NPI:1063622835
Name:BROUILLETTE, MARK RICHARD
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:RICHARD
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:622 N BURLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:NE
Mailing Address - Zip Code:68467-3030
Mailing Address - Country:US
Mailing Address - Phone:402-362-3222
Mailing Address - Fax:
Practice Address - Street 1:622 N BURLINGTON AVE
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:NE
Practice Address - Zip Code:68467-3030
Practice Address - Country:US
Practice Address - Phone:402-362-3222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice