Provider Demographics
NPI:1073029591
Name:ROUSHDY, SALLY M
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:M
Last Name:ROUSHDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:752 WESTGATE ST
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52246-4637
Mailing Address - Country:US
Mailing Address - Phone:352-281-7399
Mailing Address - Fax:
Practice Address - Street 1:801 NEWTON ROAD
Practice Address - Street 2:UNIVERSITY OF IOWA COLLEGE OF DENTISTRY
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:319-335-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAFAC-401791223P0700X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0700XDental ProvidersDentistProsthodontics