Provider Demographics
NPI:1841976842
Name:ROUSTIO, PARKER (DMD)
Entity type:Individual
Prefix:DR
First Name:PARKER
Middle Name:
Last Name:ROUSTIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8422 BRAESWOOD ESTATES DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-4247
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1002 E WESLEY DR STE 200
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-6143
Practice Address - Country:US
Practice Address - Phone:618-628-7080
Practice Address - Fax:618-628-9235
Is Sole Proprietor?:No
Enumeration Date:2023-06-23
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0344891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice