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General NPI Number Information
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NPI Number | 1003133174
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Entity Type | Individual
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Provider Name | RUSSELL J GUYMON D.D.S., M.S.
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Gender | Male
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Dates
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Enumeration Date | 04/28/2010
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Last Update Date | 10/20/2014
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Provider Practice Location Address
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Address Line | 191 N 200 E
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City | LOGAN
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State | UT
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Zip | 84321-4605
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Country | US
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Telephone | 435-752-5991
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Fax |
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Provider Business Mailing Address
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Address Line | 191 N 200 E
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City | LOGAN
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State | UT
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Zip | 84321-4605
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Country | US
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Telephone | 435-752-5991
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-4402-OR
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8908035
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License Number State | UT
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