Provider Demographics
NPI:1578926895
Name:ROUSSEAU, KRISTYN LOUGHERY (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTYN
Middle Name:LOUGHERY
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:KRISTYN
Other - Middle Name:
Other - Last Name:LOUGHERY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1025 DAVIDS RUN
Mailing Address - Street 2:
Mailing Address - City:PHOENIXVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19460-4059
Mailing Address - Country:US
Mailing Address - Phone:610-291-7075
Mailing Address - Fax:
Practice Address - Street 1:2544 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-3021
Practice Address - Country:US
Practice Address - Phone:800-585-1893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040699122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist