Provider Demographics
NPI:1154534253
Name:GILPATRICK, RUSSELL O (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:O
Last Name:GILPATRICK
Suffix:
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 1:875 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38163-0001
Mailing Address - Country:US
Mailing Address - Phone:901-448-6202
Mailing Address - Fax:901-448-1625
Practice Address - Street 1:875 UNION AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-0001
Practice Address - Country:US
Practice Address - Phone:901-448-6202
Practice Address - Fax:901-448-1625
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000051931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice