Provider Demographics
NPI:1154437408
Name:ROUSSON, DOMINIQUE D (DMD)
Entity type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:D
Last Name:ROUSSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WATETOWN ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465
Mailing Address - Country:US
Mailing Address - Phone:617-965-1321
Mailing Address - Fax:617-965-2412
Practice Address - Street 1:1001 WATERTOWN ST.
Practice Address - Street 2:
Practice Address - City:WEST NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465
Practice Address - Country:US
Practice Address - Phone:617-965-1321
Practice Address - Fax:617-965-2412
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA 17814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMA 17814OtherDENTAL LIC#