Provider Demographics
NPI:1093909434
Name:RUSSELL, ROGER T
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:T
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1956 BERKELEY ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3202
Mailing Address - Country:US
Mailing Address - Phone:801-467-6290
Mailing Address - Fax:
Practice Address - Street 1:1956 BERKELEY ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-3202
Practice Address - Country:US
Practice Address - Phone:801-467-6290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist