Provider Demographics
NPI:1104249465
Name:RUSSELL DDS PC
Entity type:Organization
Organization Name:RUSSELL DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-377-7621
Mailing Address - Street 1:930 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98337-1551
Mailing Address - Country:US
Mailing Address - Phone:360-377-7621
Mailing Address - Fax:360-377-6265
Practice Address - Street 1:930 PARK AVE
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98337-1551
Practice Address - Country:US
Practice Address - Phone:360-377-7621
Practice Address - Fax:360-377-6265
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000096701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty