Healthcare Provider Details

I. General information

NPI: 1336256106
Provider Name (Legal Business Name): RUSSELL T. WILLIAMSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1517 NICHOLASVILLE RD STE 103
LEXINGTON KY
40503-1429
US

IV. Provider business mailing address

1517 NICHOLASVILLE RD STE 103
LEXINGTON KY
40503-1429
US

V. Phone/Fax

Practice location:
  • Phone: 859-276-2248
  • Fax: 859-276-3827
Mailing address:
  • Phone: 859-276-2248
  • Fax: 859-276-3827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4477-629
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: