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General NPI Number Information
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NPI Number | 1801282769
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Entity Type | Individual
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Provider Name | KELLY RUSTICO
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Gender | Female
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Dates
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Enumeration Date | 04/07/2015
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Last Update Date | 10/29/2023
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Provider Practice Location Address
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Address Line | 305 W 12TH AVE
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City | COLUMBUS
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State | OH
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Zip | 43210-1267
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Country | US
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Telephone | 614-292-0880
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Fax |
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Provider Business Mailing Address
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Address Line | 1189 LEICESTER PL
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City | COLUMBUS
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State | OH
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Zip | 43235-2181
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Country | US
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Telephone | 614-460-1694
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | DDS102193
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 0401414839
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License Number State | VA
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Taxonomy #3
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 30.025097
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License Number State | OH
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