Individual
RUSSELL FULLER MCKINLEY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
2600 ROSE HILL, STE 100, BOISE, ID 83705
(208) 345-1386
(208) 345-2995
Mailing address
2600 ROSE HILL, STE 100, BOISE, ID 83705
(208) 345-1386
(208) 345-2995
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D1869
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010012469
BLUE SHIELD
ID
01
—
000010012469
CARING FOUNDATION BLUE SH
—
01
—
3127302
BLUE CROSS BLUE SHIELD TN
—
01
—
532545
UNITED CONCORDIA
—
01
—
69450
BLUE CROSS
ID
Enumeration date
07/19/2006
Last updated
07/08/2007
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