Provider Demographics
NPI:1225042500
Name:FLERMOEN, RUSSELL G (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:FLERMOEN
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:PO BOX 456
Mailing Address - Street 2:611 W STATE ST SUITE B
Mailing Address - City:ST JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-0456
Mailing Address - Country:US
Mailing Address - Phone:989-224-8175
Mailing Address - Fax:
Practice Address - Street 1:611 W STATE ST
Practice Address - Street 2:SUITE B
Practice Address - City:ST JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-0456
Practice Address - Country:US
Practice Address - Phone:989-224-8175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI109421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice