Provider Demographics
NPI:1558852269
Name:RUSSELL, ERIC GORDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:GORDON
Last Name:RUSSELL
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 1:2320 E LAMBOURNE AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2708
Mailing Address - Country:US
Mailing Address - Phone:801-644-4605
Mailing Address - Fax:
Practice Address - Street 1:4465 S 900 E STE 100
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-2695
Practice Address - Country:US
Practice Address - Phone:801-281-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7301384-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice