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1639397128 NPI number — RUSSELL EDWARD KLEIN DMD

NPI Number: 1639397128
Health Care Provider/Practitioner: RUSSELL EDWARD KLEIN DMD

Information about “1639397128” NPI (RUSSELL EDWARD KLEIN DMD) exists in 1639397128 in HTML format HTML  |  1639397128 in plain Text format TXT  |  1639397128 in PDF (Portable Document Format) PDF  |  1639397128 in an XML format XML  formats.

NPI Number : 1639397128 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1639397128",
    "EntityType": "Individual",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": "N",
    "IsOrgSubpart": null,
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": null,
    "LastName": "KLEIN",
    "FirstName": "RUSSELL",
    "MiddleName": "EDWARD",
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": "DMD",
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "910 IRIS LANE",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "DU QUOIN",
    "MailingAddressStateName": "IL",
    "MailingAddressPostalCode": "62832",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "618-542-2797",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "374 E GRAND AVE",
    "SecondLinePracticeLocationAddress": "STUDENT HEALTH CENTER SIVC",
    "PracticeLocationAddressCityName": "CARBONDALE",
    "PracticeLocationAddressStateName": "IL",
    "PracticeLocationAddressPostalCode": "62901",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "618-536-2421",
    "PracticeLocationAddressFaxNumber": "618-453-3477",
    "EnumerationDate": "04/23/2007",
    "LastUpdateDate": "07/08/2007",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": "M",
    "Gender": "Male",
    "AuthorizedOfficialLastName": null,
    "AuthorizedOfficialFirstName": null,
    "AuthorizedOfficialMiddleName": null,
    "AuthorizedOfficialTitle": null,
    "AuthorizedOfficialNamePrefix": null,
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": null,
    "AuthorizedOfficialTelephoneNumber": null,
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "1223G0001X",
          "TaxonomyName": "General Practice Dentistry",
          "LicenseNumber": "016106",
          "LicenseNumberStateCode": "MO",
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "1223G0001X",
          "TaxonomyName": "General Practice Dentistry",
          "LicenseNumber": null,
          "LicenseNumberStateCode": "IL",
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": null
  }
}
                
            

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