MEDICARE: ROGER T RUSSELL

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	1934	UT

General Provider Information

NPI Number	:	1093909434
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROGER T RUSSELL

Provider Business Mailing Address
First Line	:	1956 BERKELEY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3202
Country	:	US
Telephone Number	:	801-467-6290
Fax Number	:

Provider Business Practice Location Address
First Line	:	1956 BERKELEY ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-3202
Country	:	US
Telephone Number	:	801-467-6290
Fax Number	:

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

Provider Enumeration Date	:	08/29/2007
Last Update Date	:	08/29/2007

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Directions to “ ROGER T RUSSELL ” Practice Location

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