Provider Demographics
NPI:1902021827
Name:RUSSELL E. GILLIOM, D.D.S., P.C.
Entity type:Organization
Organization Name:RUSSELL E. GILLIOM, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:GILLIOM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:260-693-2177
Mailing Address - Street 1:PO BOX 265
Mailing Address - Street 2:
Mailing Address - City:CHURUBUSCO
Mailing Address - State:IN
Mailing Address - Zip Code:46723-0265
Mailing Address - Country:US
Mailing Address - Phone:260-693-2177
Mailing Address - Fax:260-693-6422
Practice Address - Street 1:230 E WHITLEY ST
Practice Address - Street 2:
Practice Address - City:CHURUBUSCO
Practice Address - State:IN
Practice Address - Zip Code:46723-1506
Practice Address - Country:US
Practice Address - Phone:260-693-2177
Practice Address - Fax:260-693-6422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN54000935A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental