Provider Demographics
NPI:1336256106
Name:WILLIAMSON, RUSSELL T (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:T
Last Name:WILLIAMSON
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 1:1517 NICHOLASVILLE RD
Mailing Address - Street 2:STE 103
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1429
Mailing Address - Country:US
Mailing Address - Phone:859-276-2248
Mailing Address - Fax:859-276-3827
Practice Address - Street 1:1517 NICHOLASVILLE RD
Practice Address - Street 2:STE 103
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-1429
Practice Address - Country:US
Practice Address - Phone:859-276-2248
Practice Address - Fax:859-276-3827
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4477-6291223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1967801Medicare ID - Type UnspecifiedMEDICARE