Provider Demographics
NPI:1568654986
Name:HUTTO, BRIAN KELLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KELLY
Last Name:HUTTO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 ST PAULS WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-3309
Mailing Address - Country:US
Mailing Address - Phone:209-522-5238
Mailing Address - Fax:209-522-4703
Practice Address - Street 1:2301 ST PAULS WAY
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-3309
Practice Address - Country:US
Practice Address - Phone:209-522-5238
Practice Address - Fax:209-522-4703
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2024-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD127981223S0112X
CA621061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery