Provider Demographics
NPI:1407298052
Name:NEAL, RUSSELL LAWRENCE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LAWRENCE
Last Name:NEAL
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 CHINQUAPIN ST
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29906-7207
Mailing Address - Country:US
Mailing Address - Phone:423-366-7572
Mailing Address - Fax:
Practice Address - Street 1:674 BOULEVARD DE FRANCE
Practice Address - Street 2:DENTAL CLINIC
Practice Address - City:PARRIS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29905
Practice Address - Country:US
Practice Address - Phone:843-228-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-24
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401414021122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist