MEDICARE: MR. RUSSELL M STEWART D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	294141-9922	UT

General Provider Information

NPI Number	:	1316089212
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RUSSELL M STEWART D.D.S.

Provider Business Mailing Address
First Line	:	1054 E RIVERSIDE DR # 100
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84790-4477
Country	:	US
Telephone Number	:	435-656-8888
Fax Number	:	435-656-8895

Provider Business Practice Location Address
First Line	:	1054 E RIVERSIDE DR # 100
Second Line	:
City	:	ST GEORGE
State	:	UT
Zip	:	84790-4477
Country	:	US
Telephone Number	:	435-656-8888
Fax Number	:	435-656-8895

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	11/18/2009

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