Provider Demographics
NPI:1134139157
Name:RUSSELL, MICHAEL A (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:RUSSELL
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 1:2240 N HIGHWAY 89
Mailing Address - Street 2:SUITE A
Mailing Address - City:HARRISVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84404-2651
Mailing Address - Country:US
Mailing Address - Phone:801-782-4745
Mailing Address - Fax:
Practice Address - Street 1:2240 N HIGHWAY 89
Practice Address - Street 2:SUITE A
Practice Address - City:HARRISVILLE
Practice Address - State:UT
Practice Address - Zip Code:84404-2651
Practice Address - Country:US
Practice Address - Phone:801-782-4745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT143024-9922-200605111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice