Provider Demographics
NPI:1235214552
Name:RUSSELL, MIKE AUGUST (DDS)
Entity Type:Individual
Prefix:MR
First Name:MIKE
Middle Name:AUGUST
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 1:7355 LATIMER DRIVE
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726
Mailing Address - Country:US
Mailing Address - Phone:225-667-2151
Mailing Address - Fax:
Practice Address - Street 1:6721 GOVERNMENT STREET
Practice Address - Street 2:SUITE A
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806
Practice Address - Country:US
Practice Address - Phone:225-924-2636
Practice Address - Fax:225-924-4424
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA43751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1843750Medicaid
LAF1517OtherBLUE CROSS BLUE SHIELD