Provider Demographics
NPI:1659409209
Name:DUPUIS, RUSSELL CREIG JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CREIG
Last Name:DUPUIS
Suffix:JR
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 1:142 LEISURE LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29210-4125
Mailing Address - Country:US
Mailing Address - Phone:803-731-9556
Mailing Address - Fax:803-731-1744
Practice Address - Street 1:142 LEISURE LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4125
Practice Address - Country:US
Practice Address - Phone:803-731-9556
Practice Address - Fax:803-731-1744
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice