Provider Demographics
NPI:1285766410
Name:DAVIS, RUSSELL LEROY (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LEROY
Last Name:DAVIS
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 1:950 I ST
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6158
Mailing Address - Country:US
Mailing Address - Phone:707-822-0525
Mailing Address - Fax:707-822-0500
Practice Address - Street 1:950 I ST
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6158
Practice Address - Country:US
Practice Address - Phone:707-822-0525
Practice Address - Fax:707-822-0500
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA234361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice