Provider Demographics
NPI:1174694004
Name:BOATWRIGHT, RUSSELL ALLEN SR (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:BOATWRIGHT
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-1077
Mailing Address - Country:US
Mailing Address - Phone:843-248-2705
Mailing Address - Fax:843-248-4202
Practice Address - Street 1:1603 10TH AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-4111
Practice Address - Country:US
Practice Address - Phone:843-248-2705
Practice Address - Fax:843-248-4202
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ27757Medicaid