Provider Demographics
NPI:1639241094
Name:RUSSELL, CAMERON M (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:M
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1051 WEST 200 NORTH
Mailing Address - Street 2:SUITE A
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037
Mailing Address - Country:US
Mailing Address - Phone:801-498-7668
Mailing Address - Fax:801-593-9581
Practice Address - Street 1:1051 WEST 200 NORTH
Practice Address - Street 2:SUITE A
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037
Practice Address - Country:US
Practice Address - Phone:801-498-7668
Practice Address - Fax:801-593-9581
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5602508-99221223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics