Provider Demographics
NPI:1194997783
Name:DR ALAN RUSSELL PLC
Entity type:Organization
Organization Name:DR ALAN RUSSELL PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUBRED
Authorized Official - Suffix:
Authorized Official - Credentials:CRDA
Authorized Official - Phone:612-336-8478
Mailing Address - Street 1:2010 27TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-1108
Mailing Address - Country:US
Mailing Address - Phone:612-336-8478
Mailing Address - Fax:
Practice Address - Street 1:2010 27TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55406-1108
Practice Address - Country:US
Practice Address - Phone:612-336-8478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN09480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160213600Medicaid
MN13D69RUOtherBLUE CROSS BLUE SHIELD
MN710609OtherUNITED OF CONCORDIA