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General NPI Number Information
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NPI Number | 1902021827
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Entity Type | Organization
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Legal Business Name | RUSSELL E. GILLIOM, D.D.S., P.C.
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Dates
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Enumeration Date | 04/16/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 230 E WHITLEY ST
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City | CHURUBUSCO
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State | IN
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Zip | 46723-1506
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Country | US
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Telephone | 260-693-2177
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Fax | 260-693-6422
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Provider Business Mailing Address
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Address Line | PO BOX 265
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City | CHURUBUSCO
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State | IN
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Zip | 46723-0265
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Country | US
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Telephone | 260-693-2177
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Fax | 260-693-6422
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RUSSELL E. GILLIOM
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Credential | D.D.S.
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Telephone | 260-693-2177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 54000935A
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License Number State | IN
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