Provider Demographics
NPI:1770769226
Name:HAUGEN, RUSSELL CRAIG (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:CRAIG
Last Name:HAUGEN
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 1:1815 SUBURBAN AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4380
Mailing Address - Country:US
Mailing Address - Phone:651-735-4661
Mailing Address - Fax:651-735-1910
Practice Address - Street 1:1815 SUBURBAN AVE STE 200
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4380
Practice Address - Country:US
Practice Address - Phone:651-735-4661
Practice Address - Fax:651-735-1910
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND9766122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist