Provider Demographics
NPI:1801908496
Name:DAVIS, RUSSELL MINOR (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:MINOR
Last Name:DAVIS
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 1:2204 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-5367
Mailing Address - Country:US
Mailing Address - Phone:772-464-4684
Mailing Address - Fax:772-465-2922
Practice Address - Street 1:2204 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-5367
Practice Address - Country:US
Practice Address - Phone:772-464-4684
Practice Address - Fax:772-465-2922
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00112401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice