Provider Demographics
NPI:1306861497
Name:CRANFORD, RUSSELL WAYNE (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:WAYNE
Last Name:CRANFORD
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 1:3626 CYPRESS ST
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-7314
Mailing Address - Country:US
Mailing Address - Phone:318-396-9667
Mailing Address - Fax:318-396-9667
Practice Address - Street 1:3626 CYPRESS ST
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-7314
Practice Address - Country:US
Practice Address - Phone:318-396-9667
Practice Address - Fax:318-396-9667
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA43251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA950793OtherUNITED CONCORDIA