MEDICARE: RUSSELL LAROY CHRISTIAN DDS

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	1223G0001X	General Practice Dentistry	4703-015	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1336149525	OTHER	WI	NPI

General Provider Information

NPI Number	:	1336149525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL LAROY CHRISTIAN DDS

Provider Business Mailing Address
First Line	:	522 SPRINGDALE ST
Second Line	:	SUITE 101
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-1780
Country	:	US
Telephone Number	:	608-437-5564
Fax Number	:	608-437-8790

Provider Business Practice Location Address
First Line	:	522 SPRINGDALE ST STE 101
Second Line	:
City	:	MOUNT HOREB
State	:	WI
Zip	:	53572-1780
Country	:	US
Telephone Number	:	608-437-5564
Fax Number	:	608-437-8790

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

Provider Enumeration Date	:	07/28/2005
Last Update Date	:	12/21/2022

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