Provider Demographics
NPI:1497995799
Name:PUTERBAUGH, RUSSELL (RDH, BS)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:
Last Name:PUTERBAUGH
Suffix:
Gender:M
Credentials:RDH, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 N QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84404-3399
Mailing Address - Country:US
Mailing Address - Phone:801-388-4034
Mailing Address - Fax:
Practice Address - Street 1:1337 N QUINCY AVE
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84404-3399
Practice Address - Country:US
Practice Address - Phone:801-388-4034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7024861-9920124Q00000X
CA24320124Q00000X
NV101503124Q00000X
AZ6457124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist