1609945674 NPI number — DR. RUSSELL LEON HARRISON DDS, MS

Table of content: DR. RUSSELL LEON HARRISON DDS, MS (NPI 1609945674)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609945674 NPI number — DR. RUSSELL LEON HARRISON DDS, MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HARRISON
Provider First Name:
RUSSELL
Provider Middle Name:
LEON
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS, MS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609945674
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 E BROADWAY
Provider Second Line Business Mailing Address:
STE. 290
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65203-4207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-449-0794
Provider Business Mailing Address Fax Number:
573-443-7333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
33 E BROADWAY
Provider Second Line Business Practice Location Address:
STE. 290
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65203-4207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-449-0794
Provider Business Practice Location Address Fax Number:
573-443-7333
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  010659 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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