Provider Demographics
NPI:1285673905
Name:LEGG, RUSSELL BROOKS VII (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:BROOKS
Last Name:LEGG
Suffix:VII
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 1:63 CARR ST
Mailing Address - Street 2:P. O. BOX 568
Mailing Address - City:CLAY
Mailing Address - State:WV
Mailing Address - Zip Code:25043-9402
Mailing Address - Country:US
Mailing Address - Phone:304-587-4232
Mailing Address - Fax:304-587-2092
Practice Address - Street 1:63 CARR ST
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:WV
Practice Address - Zip Code:25043-9402
Practice Address - Country:US
Practice Address - Phone:304-587-4232
Practice Address - Fax:304-587-2092
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVWV-21231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135486000Medicaid
WVWV2123OtherSTATE LICENSE
000728088OtherMT. STATE BC/BS INSURANCE
728088OtherUNITED CONCORDIA INSURANC
WV55-0560454OtherFEIN NUMBER