Provider Demographics
NPI:1336100569
Name:HANES, RUSSELL K (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:K
Last Name:HANES
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 1:1900 PASEO SAN LUIS
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-4614
Mailing Address - Country:US
Mailing Address - Phone:520-458-2415
Mailing Address - Fax:
Practice Address - Street 1:1900 PASEO SAN LUIS
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-4614
Practice Address - Country:US
Practice Address - Phone:520-458-2415
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice