Provider Demographics
NPI:1770709511
Name:BOULTON, RUSSELL LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LYNN
Last Name:BOULTON
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 1:2180 E 4500 S
Mailing Address - Street 2:#275
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4434
Mailing Address - Country:US
Mailing Address - Phone:801-277-9681
Mailing Address - Fax:
Practice Address - Street 1:2180 E 4500 S
Practice Address - Street 2:#275
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4434
Practice Address - Country:US
Practice Address - Phone:801-277-9681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1315701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice