Provider Demographics
NPI:1700097805
Name:DUSSEAU, ANNETTE (DDS)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:
Last Name:DUSSEAU
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:SAPPHIRE DENTAL GROUP, PC
Mailing Address - Street 2:2901 BROOKS ST.
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801
Mailing Address - Country:US
Mailing Address - Phone:406-541-2886
Mailing Address - Fax:
Practice Address - Street 1:SAPPHIRE DENTAL GROUP, PC
Practice Address - Street 2:2901 BROOKS ST.
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801
Practice Address - Country:US
Practice Address - Phone:406-541-2886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT20161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT11-1333Medicaid