Provider Demographics
NPI:1609471499
Name:BILLY D RUSSOM, DDS
Entity Type:Organization
Organization Name:BILLY D RUSSOM, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE CLERK
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-857-3557
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:CORNING
Mailing Address - State:AR
Mailing Address - Zip Code:72422-0435
Mailing Address - Country:US
Mailing Address - Phone:708-573-5578
Mailing Address - Fax:870-857-5128
Practice Address - Street 1:211 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-7259
Practice Address - Country:US
Practice Address - Phone:870-857-3557
Practice Address - Fax:870-857-5128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1114013067Medicaid