Provider Demographics
NPI:1861929846
Name:DURHAM, RAYMOND RUSSELL (DMD)
Entity type:Individual
Prefix:
First Name:RAYMOND
Middle Name:RUSSELL
Last Name:DURHAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 SHARPSHOOTER DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84025-2688
Mailing Address - Country:US
Mailing Address - Phone:435-256-5062
Mailing Address - Fax:
Practice Address - Street 1:991 SHEPARD LN STE 100
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:UT
Practice Address - Zip Code:84025-2973
Practice Address - Country:US
Practice Address - Phone:801-447-5437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-22
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10336372-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist