Provider Demographics
NPI:1114007887
Name:RUSSELL, WILLIAM DIRK (DMD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM DIRK
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:DIRK
Other - Middle Name:W
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8014 CUMMING HWY SUITE 401
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115
Mailing Address - Country:US
Mailing Address - Phone:770-345-2010
Mailing Address - Fax:770-345-0571
Practice Address - Street 1:8014 CUMMING HWY SUITE 401
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115
Practice Address - Country:US
Practice Address - Phone:770-345-2010
Practice Address - Fax:770-345-0571
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYDN0121581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice