Provider Demographics
NPI:1366129223
Name:RUSSELL, GRANT CHRISTIAN (DMD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:CHRISTIAN
Last Name:RUSSELL
Suffix:
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 1:1859 EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4753
Mailing Address - Country:US
Mailing Address - Phone:573-286-7977
Mailing Address - Fax:
Practice Address - Street 1:1203 W DELMAR AVE
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1739
Practice Address - Country:US
Practice Address - Phone:618-466-3140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0344681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice