Provider Demographics
NPI:1982621686
Name:BOESTER, RUSSELL GENE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GENE
Last Name:BOESTER
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 1:513 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1697
Mailing Address - Country:US
Mailing Address - Phone:618-833-4471
Mailing Address - Fax:
Practice Address - Street 1:513 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1697
Practice Address - Country:US
Practice Address - Phone:618-833-4471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0221461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice