Provider Demographics
NPI:1144610692
Name:RUSH, PATRICK KYLE
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:KYLE
Last Name:RUSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 E. 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:306 E 6TH AVE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161
Practice Address - Country:US
Practice Address - Phone:706-291-8062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-04
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0127601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice