Provider Demographics
NPI:1588554489
Name:KIST, ALYSSA NIKOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:ALYSSA
Middle Name:NIKOLE
Last Name:KIST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ELK CT
Mailing Address - Street 2:
Mailing Address - City:BLUE BELL
Mailing Address - State:PA
Mailing Address - Zip Code:19422-1458
Mailing Address - Country:US
Mailing Address - Phone:215-630-3731
Mailing Address - Fax:
Practice Address - Street 1:333 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:NJ
Practice Address - Zip Code:07940-2370
Practice Address - Country:US
Practice Address - Phone:973-822-2308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-03
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI031027001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics