Provider Demographics
NPI:1336149525
Name:CHRISTIAN, RUSSELL LAROY (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:LAROY
Last Name:CHRISTIAN
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 1:522 SPRINGDALE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOUNT HOREB
Mailing Address - State:WI
Mailing Address - Zip Code:53572-1780
Mailing Address - Country:US
Mailing Address - Phone:608-437-5564
Mailing Address - Fax:608-437-8790
Practice Address - Street 1:522 SPRINGDALE ST STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT HOREB
Practice Address - State:WI
Practice Address - Zip Code:53572-1780
Practice Address - Country:US
Practice Address - Phone:608-437-5564
Practice Address - Fax:608-437-8790
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4703-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1336149525OtherNPI