Provider Demographics
NPI:1639397128
Name:KLEIN, RUSSELL EDWARD (DMD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:EDWARD
Last Name:KLEIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 IRIS LANE
Mailing Address - Street 2:
Mailing Address - City:DU QUOIN
Mailing Address - State:IL
Mailing Address - Zip Code:62832
Mailing Address - Country:US
Mailing Address - Phone:618-542-2797
Mailing Address - Fax:
Practice Address - Street 1:374 E GRAND AVE
Practice Address - Street 2:STUDENT HEALTH CENTER SIVC
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-536-2421
Practice Address - Fax:618-453-3477
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0161061223G0001X
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice