Provider Demographics
NPI:1063572162
Name:BACKUS, GILBERT RUSSELL JR (DDS)
Entity type:Individual
Prefix:DR
First Name:GILBERT
Middle Name:RUSSELL
Last Name:BACKUS
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 BOARDMAN CANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOARDMAN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4200
Mailing Address - Country:US
Mailing Address - Phone:330-758-7931
Mailing Address - Fax:
Practice Address - Street 1:810 BOARDMAN CANFIELD RD
Practice Address - Street 2:
Practice Address - City:BOARDMAN
Practice Address - State:OH
Practice Address - Zip Code:44512-4200
Practice Address - Country:US
Practice Address - Phone:330-758-7931
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30013429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist