Provider Demographics
NPI:1417172321
Name:GILLIOM, RUSSELL ERIC (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ERIC
Last Name:GILLIOM
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:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-0265
Mailing Address - Country:US
Mailing Address - Phone:260-693-2177
Mailing Address - Fax:260-693-6422
Practice Address - Street 1:230 E WHITLEY ST
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-1506
Practice Address - Country:US
Practice Address - Phone:260-693-2177
Practice Address - Fax:260-693-6422
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007296122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist