Basic Information
| Provider Information | |||||||||
| NPI: | 1285673905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEGG | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | BROOKS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | VII | ||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 CARR ST | ||||||||
| Address2: | P. O. BOX 568 | ||||||||
| City: | CLAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250439402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045874232 | ||||||||
| FaxNumber: | 3045872092 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 CARR ST | ||||||||
| Address2: | |||||||||
| City: | CLAY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 250439402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3045874232 | ||||||||
| FaxNumber: | 3045872092 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | WV-2123 | WV | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 0135486000 | 05 | WV | MEDICAID | WV2123 | 01 | WV | STATE LICENSE | OTHER | 000728088 | 01 | MT. STATE BC/BS INSURANCE | OTHER | 728088 | 01 | UNITED CONCORDIA INSURANC | OTHER | 55-0560454 | 01 | WV | FEIN NUMBER | OTHER |