Healthcare Provider Details

I. General information

NPI: 1982700761
Provider Name (Legal Business Name): RUSSELL C GOURLEY III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 12/21/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6231 PENN DRIVE
BUTLER PA
16002
US

IV. Provider business mailing address

6231 PENN DRIVE
BUTLER PA
16002
US

V. Phone/Fax

Practice location:
  • Phone: 724-586-7400
  • Fax: 724-586-7400
Mailing address:
  • Phone: 724-586-7400
  • Fax: 724-586-7400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS018946L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: