Healthcare Provider Details

I. General information

NPI: 1700875671
Provider Name (Legal Business Name): RUSSELL ARBREY HULSE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 N KENTUCKY ST
KINGSTON TN
37763-2328
US

IV. Provider business mailing address

1203 OLD N KENTUCKY ST
KINGSTON TN
37763-2358
US

V. Phone/Fax

Practice location:
  • Phone: 865-717-3586
  • Fax:
Mailing address:
  • Phone: 865-717-3586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS8165
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: