Provider Demographics
NPI:1497878821
Name:EDMAN, RUSSELL GEORGE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GEORGE
Last Name:EDMAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2977 CHURCH ST. P.O. BOX 178
Mailing Address - Street 2:
Mailing Address - City:PINE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:12567-0178
Mailing Address - Country:US
Mailing Address - Phone:518-398-5311
Mailing Address - Fax:518-398-9536
Practice Address - Street 1:2977 CHURCH ST.
Practice Address - Street 2:
Practice Address - City:PINE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:12567-0178
Practice Address - Country:US
Practice Address - Phone:518-398-5311
Practice Address - Fax:518-398-9536
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042-5421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice