MEDICARE: DR. RUSEL PAUL HOLLISTER D.D.S, M.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	2901012996	MI

General Provider Information

NPI Number	:	1487745774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSEL PAUL HOLLISTER D.D.S, M.S.

Provider Business Mailing Address
First Line	:	4426 W KL AVE
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-5723
Country	:	US
Telephone Number	:	269-353-7700
Fax Number	:	269-353-7788

Provider Business Practice Location Address
First Line	:	4426 W KL AVE
Second Line	:
City	:	KALAMAZOO
State	:	MI
Zip	:	49006-5723
Country	:	US
Telephone Number	:	269-353-7700
Fax Number	:	269-353-7788

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

Provider Enumeration Date	:	09/28/2006
Last Update Date	:	07/08/2007

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