Provider Demographics
NPI:1851640478
Name:DEROSIA, KRISTY LYNN (RDH)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:LYNN
Last Name:DEROSIA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LONDON RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2433
Mailing Address - Country:US
Mailing Address - Phone:218-481-7474
Mailing Address - Fax:218-789-4150
Practice Address - Street 1:1420 LONDON RD
Practice Address - Street 2:SUITE 206
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2433
Practice Address - Country:US
Practice Address - Phone:218-481-7474
Practice Address - Fax:218-789-4150
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNH4727124Q00000X
WI10916-016124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist