Provider Demographics
NPI:1215145693
Name:THALER, RUSSELL T (DMD,MS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:T
Last Name:THALER
Suffix:
Gender:M
Credentials:DMD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9024 CEDAR BEND RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-9394
Mailing Address - Country:US
Mailing Address - Phone:419-340-8455
Mailing Address - Fax:
Practice Address - Street 1:5757 MONCLOVA RD
Practice Address - Street 2:SUITE 12
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1863
Practice Address - Country:US
Practice Address - Phone:419-893-0253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0230001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics