Provider Demographics
NPI:1669518742
Name:BOYD, RUSSELL LANE (DMD, PC)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:LANE
Last Name:BOYD
Suffix:
Gender:M
Credentials:DMD, PC
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7000 PEACHTREE DUNWOODY RD NE
Mailing Address - Street 2:BUILDING 2, SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-1655
Mailing Address - Country:US
Mailing Address - Phone:770-351-9222
Mailing Address - Fax:770-351-0463
Practice Address - Street 1:7000 PEACHTREE DUNWOODY RD
Practice Address - Street 2:BUILDING 2, SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-1655
Practice Address - Country:US
Practice Address - Phone:770-351-9222
Practice Address - Fax:770-351-0463
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-29
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA114071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582663987OtherTAX ID