Healthcare Provider Details

I. General information

NPI: 1568654986
Provider Name (Legal Business Name): BRIAN KELLY HUTTO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2007
Last Update Date: 02/04/2024
Certification Date: 02/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ST PAULS WAY
MODESTO CA
95355-3309
US

IV. Provider business mailing address

2301 ST PAULS WAY
MODESTO CA
95355-3309
US

V. Phone/Fax

Practice location:
  • Phone: 209-522-5238
  • Fax: 209-522-4703
Mailing address:
  • Phone: 209-522-5238
  • Fax: 209-522-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12798
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number62106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: