Provider Demographics
NPI:1821161902
Name:POOLE, RUSSELL ALLEN (DMD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:ALLEN
Last Name:POOLE
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 1:2111 CHAMPA ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80205-2529
Mailing Address - Country:US
Mailing Address - Phone:303-293-2220
Mailing Address - Fax:
Practice Address - Street 1:2111 CHAMPA ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80205-2529
Practice Address - Country:US
Practice Address - Phone:303-293-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9212122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist