Provider Demographics
NPI:1154665073
Name:MORRISTOWN FAMILY DENTISTRY, LLC
Entity Type:Organization
Organization Name:MORRISTOWN FAMILY DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:S
Authorized Official - Last Name:STAGGS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-763-6412
Mailing Address - Street 1:347 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46161-9792
Mailing Address - Country:US
Mailing Address - Phone:765-763-6412
Mailing Address - Fax:765-763-6815
Practice Address - Street 1:347 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:IN
Practice Address - Zip Code:46161-9792
Practice Address - Country:US
Practice Address - Phone:765-763-6412
Practice Address - Fax:765-763-6815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN19010197122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty