Provider Demographics
NPI:1205806411
Name:RUSSELL, RAND KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:RAND
Middle Name:KEITH
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5745 ERINDALE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-8902
Mailing Address - Country:US
Mailing Address - Phone:719-599-7665
Mailing Address - Fax:719-599-8599
Practice Address - Street 1:5745 ERINDALE DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-8902
Practice Address - Country:US
Practice Address - Phone:719-599-7665
Practice Address - Fax:719-599-8599
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD59251223G0001X
NC104561223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
BR8445872OtherFEDERAL DEA