Provider Demographics
NPI:1457370686
Name:MCKINLEY, RUSSELL FULLER (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:FULLER
Last Name:MCKINLEY
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 1:2600 ROSE HILL
Mailing Address - Street 2:STE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705
Mailing Address - Country:US
Mailing Address - Phone:208-345-1386
Mailing Address - Fax:208-345-2995
Practice Address - Street 1:2600 ROSE HILL
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705
Practice Address - Country:US
Practice Address - Phone:208-345-1386
Practice Address - Fax:208-345-2995
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010012469OtherBLUE SHIELD
000010012469OtherCARING FOUNDATION BLUE SH
532545OtherUNITED CONCORDIA
3127302OtherBLUE CROSS BLUE SHIELD TN
ID69450OtherBLUE CROSS