Provider Demographics
NPI:1114091600
Name:RUSSELL A. BOATWRIGHT, D.M.D., P.C.
Entity Type:Organization
Organization Name:RUSSELL A. BOATWRIGHT, D.M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BOATWRIGHT
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:843-248-2705
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-1077
Mailing Address - Country:US
Mailing Address - Phone:843-248-2705
Mailing Address - Fax:843-248-4202
Practice Address - Street 1:1603 10TH AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4111
Practice Address - Country:US
Practice Address - Phone:843-248-2705
Practice Address - Fax:843-248-4202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9860Medicaid