MEDICARE: KELLY M TROUT DMD PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3410-07	MS

General Provider Information

NPI Number	:	1538506282
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY M TROUT DMD PLLC

Provider Business Mailing Address
First Line	:	2228 MILITARY RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2456
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2228 MILITARY RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2456
Country	:	US
Telephone Number	:	662-328-0044
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KELLY M TROUT
Credential	:	DMD
Telephone Number	:	662-549-1545

Provider Enumeration Date	:	06/03/2013
Last Update Date	:	06/03/2013

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