Provider Demographics
NPI:1003171497
Name:HUSTON, KELLY MICHAEL (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHAEL
Last Name:HUSTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 E PARK AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:OTTUMWA
Mailing Address - State:IA
Mailing Address - Zip Code:52501-2069
Mailing Address - Country:US
Mailing Address - Phone:319-610-3505
Mailing Address - Fax:
Practice Address - Street 1:415 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-3027
Practice Address - Country:US
Practice Address - Phone:641-684-0215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice