Provider Demographics
NPI:1588743595
Name:TROUT, KELLY MCIVER (DMD)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MCIVER
Last Name:TROUT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-2456
Mailing Address - Country:US
Mailing Address - Phone:662-328-0044
Mailing Address - Fax:662-328-0046
Practice Address - Street 1:2228 MILITARY RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2456
Practice Address - Country:US
Practice Address - Phone:662-328-0044
Practice Address - Fax:662-328-0046
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL5084122300000X
MS3410-07122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist