Provider Demographics
NPI:1386073054
Name:SHARON RUSSELL DDS PC
Entity type:Organization
Organization Name:SHARON RUSSELL DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-320-7331
Mailing Address - Street 1:9632 MARLBORO PIKE
Mailing Address - Street 2:MELWOOD PROFESSIONAL CENTER
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-3670
Mailing Address - Country:US
Mailing Address - Phone:240-320-7331
Mailing Address - Fax:
Practice Address - Street 1:9632 MARLBORO PIKE
Practice Address - Street 2:MELWOOD PROFESSIONAL CENTER
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-3670
Practice Address - Country:US
Practice Address - Phone:240-320-7331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARYLAND DENTAL SPECIALIST
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14351122300000X, 1223G0001X
1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD14351Medicaid