Provider Demographics
NPI:1356471213
Name:RUSSELL, CHAD D (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:123 MAIN ST #1
Mailing Address - City:THREE FORKS
Mailing Address - State:MT
Mailing Address - Zip Code:59752-0850
Mailing Address - Country:US
Mailing Address - Phone:406-285-5234
Mailing Address - Fax:
Practice Address - Street 1:123 MAIN ST
Practice Address - Street 2:SUITE #1
Practice Address - City:THREE FORKS
Practice Address - State:MT
Practice Address - Zip Code:59752-0850
Practice Address - Country:US
Practice Address - Phone:406-285-5234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT2117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist