Provider Demographics
NPI:1407159197
Name:RELYEA, RUSSELL E (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:E
Last Name:RELYEA
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 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0343
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:8744 W FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8207
Practice Address - Country:US
Practice Address - Phone:208-322-3010
Practice Address - Fax:208-322-9273
Is Sole Proprietor?:No
Enumeration Date:2010-12-17
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1265122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist