Provider Demographics
NPI:1235142803
Name:RUSSELL, MONTE H (DDS)
Entity Type:Individual
Prefix:DR
First Name:MONTE
Middle Name:H
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 1:29 PLYMOUTH ST NE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031
Mailing Address - Country:US
Mailing Address - Phone:712-546-8823
Mailing Address - Fax:712-546-9477
Practice Address - Street 1:29 PLYMOUTH ST NE
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031
Practice Address - Country:US
Practice Address - Phone:712-546-8823
Practice Address - Fax:712-546-9477
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA05974122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0005173Medicaid