Provider Demographics
NPI:1801956248
Name:DUSSAULT, KIRSTEN JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:KIRSTEN
Middle Name:JEAN
Last Name:DUSSAULT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KIRSTEN
Other - Middle Name:JEAN
Other - Last Name:LANGGUTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1349 ROMEO CT
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-4523
Mailing Address - Country:US
Mailing Address - Phone:612-386-6481
Mailing Address - Fax:
Practice Address - Street 1:13911 RIDGEDALE DR
Practice Address - Street 2:SUITE 395
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1771
Practice Address - Country:US
Practice Address - Phone:952-545-8603
Practice Address - Fax:952-545-4371
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice