Healthcare Provider Details

I. General information

NPI: 1639512015
Provider Name (Legal Business Name): RUSSELL BULLEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 S PUEBLO BLVD
PUEBLO CO
81005-1507
US

IV. Provider business mailing address

1221 S PUEBLO BLVD
PUEBLO CO
81005-1507
US

V. Phone/Fax

Practice location:
  • Phone: 801-427-6715
  • Fax:
Mailing address:
  • Phone: 801-427-6715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number00203038
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number00203038
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: