Raymond Eddie Broussard, DDS

Primary specialty

DentistTaxonomy code 122300000X

License

DD1745 Issued in NM

Practice address

1724 Grande Blvd
Rio Rancho, NM 87124

Phone

(505) 896-0245

Fax

(505) 892-7579

NPI assigned

Aug 24, 2006

Last updated

Jul 8, 2007By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Interoperability endpoints

• Direct secure messaging: rbroussard7012@ahs.direct-ci.com

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Westside Pediatric Dentistry

  • Pediatric Dentistry
  • Rio Rancho, NM
  • NPI 1790808111
  NPD (past) Authorized official
• Jicarilla IHS Pharmacy

  dba Dulce IHS Pharmacy

  • Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
  • Dulce, NM
  • NPI 1124220900
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1156377600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1183852800000",
    "number": "1558478560",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1724 GRANDE BLVD",
            "city": "RIO RANCHO",
            "state": "NM",
            "postal_code": "87124",
            "telephone_number": "505-896-0245",
            "fax_number": "505-892-7579"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1724 GRANDE BLVD",
            "city": "RIO RANCHO",
            "state": "NM",
            "postal_code": "87124",
            "telephone_number": "505-896-0245",
            "fax_number": "505-892-7579"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROUSSARD",
        "first_name": "RAYMOND",
        "middle_name": "EDDIE",
        "name_prefix": "Mr.",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-08-24",
        "last_updated": "2007-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "NM",
            "license": "DD1745",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "83918",
            "state": "NM"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Landrick O'Keith Brody
• Hollye A Bronson, OTRL
• Charlene E Broock, MSW, LICSW
• Amie Brooks
• Mariah Raine Brooks
• Darren Gregory Brown, LPCC
• David Brown
• Jaime Brown, ASN
• Jeffery Brown, M.D.
• Lance Brown

• Dentist in Rio Rancho, NM
• Providers in Rio Rancho, NM by specialty
• Dentist in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.