Provider Demographics
NPI:1306053988
Name:RUSSELL, BRETT V (DDS)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:V
Last Name:RUSSELL
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 1:2310 FORUM BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5461
Mailing Address - Country:US
Mailing Address - Phone:573-446-0032
Mailing Address - Fax:573-446-0238
Practice Address - Street 1:2310 FORUM BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65203-5461
Practice Address - Country:US
Practice Address - Phone:573-446-0032
Practice Address - Fax:573-446-0238
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO129331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO103550OtherBLUE CROSS BLUE SHIELD
MO860382OtherUNITED CONCORDIA