MEDICARE: MRS. KELLY MCIVER TROUT DMD

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	122300000X	Dentist	5084	AL
2	122300000X	Dentist	3410-07	MS

General Provider Information

NPI Number	:	1588743595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MCIVER TROUT DMD

Provider Business Mailing Address
First Line	:	2228 MILITARY RD
Second Line	:
City	:	COLUMBUS
State	:	MS
Zip	:	39705-2456
Country	:	US
Telephone Number	:	662-328-0044
Fax Number	:	662-328-0046

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	:	662-328-0046

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/02/2006
Last Update Date	:	04/15/2013

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