Provider Demographics
NPI:1992905129
Name:KIMBERLY T. LOUGH, DDS, MS, PLLC
Entity type:Organization
Organization Name:KIMBERLY T. LOUGH, DDS, MS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:T
Authorized Official - Last Name:LOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:304-722-7221
Mailing Address - Street 1:12 KANAWHA TERRACE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ST ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-722-7221
Mailing Address - Fax:304-722-0420
Practice Address - Street 1:12 KANAWHA TER
Practice Address - Street 2:SUITE B
Practice Address - City:ST ALBANS
Practice Address - State:WV
Practice Address - Zip Code:25177
Practice Address - Country:US
Practice Address - Phone:304-722-7221
Practice Address - Fax:304-722-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV34151223P0221X
WV37831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV4004039000Medicaid