Provider Demographics
NPI:1528153095
Name:SONNTAG, RUSSELL PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:PETER
Last Name:SONNTAG
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 REDWOOD LANE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005
Mailing Address - Country:US
Mailing Address - Phone:719-564-1102
Mailing Address - Fax:719-565-0234
Practice Address - Street 1:4130 REDWOOD LANE
Practice Address - Street 2:SUITE 130
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005
Practice Address - Country:US
Practice Address - Phone:719-564-1102
Practice Address - Fax:719-565-0234
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO91821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice