Individual
DR. RUSSELL BROOKS LEGG VII
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
63 CARR ST, CLAY, WV 25043-9402
(304) 587-4232
(304) 587-2092
Mailing address
63 CARR ST, P. O. BOX 568, CLAY, WV 25043-9402
(304) 587-4232
(304) 587-2092
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
WV-2123
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000728088
MT. STATE BC/BS INSURANCE
—
05
—
0135486000
—
WV
01
—
55-0560454
FEIN NUMBER
WV
01
—
728088
UNITED CONCORDIA INSURANC
—
01
—
WV2123
STATE LICENSE
WV
Enumeration date
06/06/2006
Last updated
12/13/2011
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