Provider Demographics
NPI:1881829257
Name:SEARLE, RUSSELL KENT (DMD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:KENT
Last Name:SEARLE
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 1:4431 68TH ST
Mailing Address - Street 2:US ARMY DENTAL ACTIVITY - ATTN: TATIANA SLAUGHTER
Mailing Address - City:FORT HOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76544-5042
Mailing Address - Country:US
Mailing Address - Phone:254-287-2705
Mailing Address - Fax:254-287-1786
Practice Address - Street 1:10590 ENDURING FREEDOM DR
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5503
Practice Address - Country:US
Practice Address - Phone:315-772-6234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR09194122300000X
ORD91941223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist