Healthcare Provider Details

I. General information

NPI: 1700673217
Provider Name (Legal Business Name): KYLE HOLLIS, DMD OF RUSTON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 W ALABAMA AVE
RUSTON LA
71270-4265
US

IV. Provider business mailing address

303 W ALABAMA AVE
RUSTON LA
71270-4265
US

V. Phone/Fax

Practice location:
  • Phone: 318-255-8648
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASEY CASTLE
Title or Position: DIRECTOR OF PAYOR CONTRACTS
Credential:
Phone: 912-732-1504