Healthcare Provider Details

I. General information

NPI: 1801282769
Provider Name (Legal Business Name): KELLY RUSTICO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2015
Last Update Date: 10/29/2023
Certification Date: 10/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W 12TH AVE
COLUMBUS OH
43210-1267
US

IV. Provider business mailing address

1189 LEICESTER PL
COLUMBUS OH
43235-2181
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-0880
  • Fax:
Mailing address:
  • Phone: 614-460-1694
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.025097
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS102193
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401414839
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: