Provider Demographics
NPI:1558412452
Name:GORMAN, RUSSELL MCCLAIN (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MCCLAIN
Last Name:GORMAN
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 1:308 WEST ST LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913
Mailing Address - Country:US
Mailing Address - Phone:501-321-1977
Mailing Address - Fax:501-321-1750
Practice Address - Street 1:308 WEST ST LOUIS ST
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-4406
Practice Address - Country:US
Practice Address - Phone:501-321-1977
Practice Address - Fax:501-321-1750
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR32381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5T948OtherBCBS
AR975194OtherUNITED CONCORDIA