Provider Demographics
NPI:1891852083
Name:DOERINGER, RUSSELL CLIFFORD (DMD PC)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:CLIFFORD
Last Name:DOERINGER
Suffix:
Gender:M
Credentials:DMD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4626 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3535
Mailing Address - Country:US
Mailing Address - Phone:248-674-0384
Mailing Address - Fax:248-674-1483
Practice Address - Street 1:4626 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3535
Practice Address - Country:US
Practice Address - Phone:248-674-0384
Practice Address - Fax:248-674-1483
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010096681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4006361Medicare ID - Type Unspecified