Individual
GRANT CHRISTIAN RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
1203 W DELMAR AVE, GODFREY, IL 62035-1739
(618) 466-3140
Mailing address
1859 EVERGREEN AVE, ALTON, IL 62002-4753
(573) 286-7977
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
019.034468
IL
Other
Enumeration date
07/03/2023
Last updated
07/03/2023
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