MEDICARE: DR. DAVID A RUSSELL 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	D12399	MN

General Provider Information

NPI Number	:	1417153818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID A RUSSELL DDS

Provider Business Mailing Address
First Line	:	400 N BENTON DR
Second Line	:
City	:	SAUK RAPIDS
State	:	MN
Zip	:	56379-1535
Country	:	US
Telephone Number	:	320-253-4206
Fax Number	:	320-202-7803

Provider Business Practice Location Address
First Line	:	400 N BENTON DR
Second Line	:
City	:	SAUK RAPIDS
State	:	MN
Zip	:	56379-1535
Country	:	US
Telephone Number	:	320-253-4206
Fax Number	:	320-202-7803

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

Provider Enumeration Date	:	06/22/2007
Last Update Date	:	07/08/2007

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