Provider Demographics
NPI:1093977647
Name:RUSSELL C. POOL, DMD, PA
Entity Type:Organization
Organization Name:RUSSELL C. POOL, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:C
Authorized Official - Last Name:POOL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-467-2545
Mailing Address - Street 1:109 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5047
Mailing Address - Country:US
Mailing Address - Phone:208-467-2545
Mailing Address - Fax:208-466-3607
Practice Address - Street 1:109 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5047
Practice Address - Country:US
Practice Address - Phone:208-467-2545
Practice Address - Fax:208-466-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1687261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID66852OtherBLUE SHIELD OF IDAHO