Provider Demographics
NPI:1003151390
Name:LEGACY HILL DENTISTRY
Entity Type:Organization
Organization Name:LEGACY HILL DENTISTRY
Other - Org Name:RICKY DALE RUSSELL, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:615-459-8050
Mailing Address - Street 1:526 LEGACY DR
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-6750
Mailing Address - Country:US
Mailing Address - Phone:615-459-8050
Mailing Address - Fax:615-459-6023
Practice Address - Street 1:526 LEGACY DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6750
Practice Address - Country:US
Practice Address - Phone:615-459-8050
Practice Address - Fax:615-459-6023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty