Provider Demographics
NPI:1225179047
Name:BERT D. ROULEAU D.M.D, M.S. INK
Entity type:Organization
Organization Name:BERT D. ROULEAU D.M.D, M.S. INK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RDA
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-964-6400
Mailing Address - Street 1:1174 CASTRO ST STE 120
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-2569
Mailing Address - Country:US
Mailing Address - Phone:650-964-6400
Mailing Address - Fax:650-964-0797
Practice Address - Street 1:1174 CASTRO ST STE 120
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94040-2569
Practice Address - Country:US
Practice Address - Phone:650-964-6400
Practice Address - Fax:650-964-0797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty