MEDICARE: DR. RUSSELL LYNN BOULTON 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	131570	UT

General Provider Information

NPI Number	:	1770709511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL LYNN BOULTON DDS

Provider Business Mailing Address
First Line	:	2180 E 4500 S
Second Line	:	#275
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-277-9681
Fax Number	:

Provider Business Practice Location Address
First Line	:	2180 E 4500 S
Second Line	:	#275
City	:	HOLLADAY
State	:	UT
Zip	:	84117-4434
Country	:	US
Telephone Number	:	801-277-9681
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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