Individual
KELLY RUSTICO
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
305 W 12TH AVE, COLUMBUS, OH 43210-1267
(614) 292-0880
Mailing address
1189 LEICESTER PL, COLUMBUS, OH 43235-2181
(614) 460-1694
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
30.025097
OH
1223G0001X
General Practice Dentistry
0401414839
VA
1223G0001X
General Practice Dentistry
DDS102193
CA
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/07/2015
Last updated
10/29/2023
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