Healthcare Provider Details

I. General information

NPI: 1477529444
Provider Name (Legal Business Name): DAVID DOSHIER RUSSELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 N BROADWAY ST
PITTSBURG KS
66762-3910
US

IV. Provider business mailing address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-6788
  • Fax: 620-231-2331
Mailing address:
  • Phone: 620-231-9873
  • Fax: 620-231-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4499
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: