Provider Demographics
NPI:1710180294
Name:DYLLA, RUSSELL ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:DYLLA
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 1:6545 FRANCE AVE S STE 190
Mailing Address - Street 2:SUITE #190
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2184
Mailing Address - Country:US
Mailing Address - Phone:952-922-6949
Mailing Address - Fax:
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:SUITE #190
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2131
Practice Address - Country:US
Practice Address - Phone:952-922-6949
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND120161223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics