Provider Demographics
NPI:1003462292
Name:ERIC G RUSSELL DDS LLC
Entity Type:Organization
Organization Name:ERIC G RUSSELL DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-644-4605
Mailing Address - Street 1:5685 S 1475 E STE 4A
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4598
Mailing Address - Country:US
Mailing Address - Phone:801-475-4646
Mailing Address - Fax:
Practice Address - Street 1:5685 S 1475 E STE 4A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4598
Practice Address - Country:US
Practice Address - Phone:801-475-4646
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-13
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental