Provider Demographics
NPI:1801080015
Name:BLACKHURST, RUSSELL D (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:BLACKHURST
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 1:913 SW HIGGINS AVE
Mailing Address - Street 2:201
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59803-1461
Mailing Address - Country:US
Mailing Address - Phone:406-721-2686
Mailing Address - Fax:406-721-1213
Practice Address - Street 1:913 SW HIGGINS AVE
Practice Address - Street 2:201
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59803-1461
Practice Address - Country:US
Practice Address - Phone:406-721-2686
Practice Address - Fax:406-721-1213
Is Sole Proprietor?:No
Enumeration Date:2007-08-30
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO9453122300000X
MT23061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist