Provider Demographics
NPI:1417153818
Name:RUSSELL, DAVID A (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:A
Last Name:RUSSELL
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 1:400 N BENTON DR
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1535
Mailing Address - Country:US
Mailing Address - Phone:320-253-4206
Mailing Address - Fax:320-202-7803
Practice Address - Street 1:400 N BENTON DR
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1535
Practice Address - Country:US
Practice Address - Phone:320-253-4206
Practice Address - Fax:320-202-7803
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND123991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice