Healthcare Provider Details

I. General information

NPI: 1326001801
Provider Name (Legal Business Name): KIMBERLY T. LOUGH DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 01/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 KANAWHA TER SUITE B
SAINT ALBANS WV
25177-2750
US

IV. Provider business mailing address

12 KANAWHA TER SUITE B
SAINT ALBANS WV
25177-2750
US

V. Phone/Fax

Practice location:
  • Phone: 304-722-7221
  • Fax: 304-722-0420
Mailing address:
  • Phone: 304-722-7221
  • Fax: 304-722-0420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3415
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: