Provider Demographics
NPI:1861607301
Name:ROUZAUD, ROBERT MICHAEL (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MICHAEL
Last Name:ROUZAUD
Suffix:
Gender:M
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:PO BOX 10576
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44110-0576
Mailing Address - Country:US
Mailing Address - Phone:216-681-0055
Mailing Address - Fax:216-681-0055
Practice Address - Street 1:1026 E 152ND ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-3330
Practice Address - Country:US
Practice Address - Phone:216-681-0055
Practice Address - Fax:216-681-0055
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-01-9103122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0762554Medicaid