Individual
MR. MIKE AUGUST RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
6721 GOVERNMENT STREET, SUITE A, BATON ROUGE, LA 70806
(225) 924-2636
(225) 924-4424
Mailing address
7355 LATIMER DRIVE, DENHAM SPRINGS, LA 70726
(225) 667-2151
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
LA4375
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1843750
—
LA
01
—
F1517
BLUE CROSS BLUE SHIELD
LA
Enumeration date
10/26/2006
Last updated
07/08/2007
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