Provider Demographics
NPI:1043286891
Name:MAYER, RUSSELL P (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:P
Last Name:MAYER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 PINE CREST DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70401-8227
Mailing Address - Country:US
Mailing Address - Phone:985-345-2285
Mailing Address - Fax:
Practice Address - Street 1:910 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70401-3038
Practice Address - Country:US
Practice Address - Phone:985-345-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA34351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1834351Medicaid