Provider Demographics
NPI:1013673193
Name:ROTHERY, KRISTEN
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:ROTHERY
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 1:12848 CABOT RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922-0621
Mailing Address - Country:US
Mailing Address - Phone:951-225-2203
Mailing Address - Fax:
Practice Address - Street 1:12848 CABOT RIDGE LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-0621
Practice Address - Country:US
Practice Address - Phone:951-225-2203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10490124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN10490OtherDENTAL HYGIENE LICENSE