MEDICARE: BENJAMIN RUSSELL D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	5729440	UT

General Provider Information

NPI Number	:	1013331339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BENJAMIN RUSSELL D.D.S.

Provider Business Mailing Address
First Line	:	2700 HOMESTEAD RD
Second Line	:	#130
City	:	PARK CITY
State	:	UT
Zip	:	84098-4857
Country	:	US
Telephone Number	:	435-940-9900
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 HOMESTEAD RD
Second Line	:	#130
City	:	PARK CITY
State	:	UT
Zip	:	84098-4857
Country	:	US
Telephone Number	:	435-940-9900
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2014
Last Update Date	:	02/06/2014

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