Provider Demographics
NPI:1497864193
Name:BOYTER, RUSSELL B (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:B
Last Name:BOYTER
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 1:1630 NW BROAD ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MURFREESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37129
Mailing Address - Country:US
Mailing Address - Phone:615-896-0608
Mailing Address - Fax:615-848-9444
Practice Address - Street 1:1630 NW BROAD ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129
Practice Address - Country:US
Practice Address - Phone:615-896-0608
Practice Address - Fax:615-848-9444
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN005230122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4033615OtherBLUE CROSS BLUE SHIELD TN