Provider Demographics
NPI:1316624729
Name:ROUSSEAU, LAURY (DDS)
Entity type:Individual
Prefix:
First Name:LAURY
Middle Name:
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 NW 49TH ST STE 125
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3750
Mailing Address - Country:US
Mailing Address - Phone:954-759-6710
Mailing Address - Fax:954-759-6767
Practice Address - Street 1:200 NW 7TH AVE
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-9026
Practice Address - Country:US
Practice Address - Phone:954-759-6610
Practice Address - Fax:954-759-6767
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN283061223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health