Provider Demographics
NPI:1205543204
Name:RUSSELLVILLE FAMILY DENTISTRY LLC
Entity type:Organization
Organization Name:RUSSELLVILLE FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLEARY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:256-332-6073
Mailing Address - Street 1:510 ENGLE DR SE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35653-2749
Mailing Address - Country:US
Mailing Address - Phone:256-332-6073
Mailing Address - Fax:256-332-6655
Practice Address - Street 1:510 ENGLE DR SE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-2749
Practice Address - Country:US
Practice Address - Phone:256-332-6073
Practice Address - Fax:256-332-6655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty