Provider Demographics
NPI:1285821884
Name:RUSSELL, THOMAS LLOYD
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LLOYD
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5125 ROE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2358
Mailing Address - Country:US
Mailing Address - Phone:913-831-4300
Mailing Address - Fax:913-831-6999
Practice Address - Street 1:607 E 64TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1129
Practice Address - Country:US
Practice Address - Phone:816-444-8969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2019-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017032912122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist