Provider Demographics
NPI:1184789687
Name:PITCH, RUSSELL H (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:H
Last Name:PITCH
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 1:140 N MARKET ST
Mailing Address - Street 2:PO BOX 315
Mailing Address - City:PAXTON
Mailing Address - State:IL
Mailing Address - Zip Code:60957-1220
Mailing Address - Country:US
Mailing Address - Phone:217-379-4649
Mailing Address - Fax:217-379-9626
Practice Address - Street 1:140 N MARKET ST
Practice Address - Street 2:
Practice Address - City:PAXTON
Practice Address - State:IL
Practice Address - Zip Code:60957-1220
Practice Address - Country:US
Practice Address - Phone:217-379-4649
Practice Address - Fax:217-379-9626
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice