Provider Demographics
NPI:1154109825
Name:WILSON, RUSSELL THOMAS (DDS, MSD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:THOMAS
Last Name:WILSON
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3005 N ANDROMEDA ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-4045
Mailing Address - Country:US
Mailing Address - Phone:307-389-9143
Mailing Address - Fax:
Practice Address - Street 1:602 N CALGARY CT STE 302
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4000
Practice Address - Country:US
Practice Address - Phone:208-777-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-5563-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics