Healthcare Provider Details

I. General information

NPI: 1205806411
Provider Name (Legal Business Name): RAND KEITH RUSSELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5745 ERINDALE DR STE 200
COLORADO SPRINGS CO
80918-8902
US

IV. Provider business mailing address

5745 ERINDALE DR STE 200
COLORADO SPRINGS CO
80918-8902
US

V. Phone/Fax

Practice location:
  • Phone: 719-599-7665
  • Fax: 719-599-8599
Mailing address:
  • Phone: 719-599-7665
  • Fax: 719-599-8599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10456
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5925
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: