Provider Demographics
NPI:1386802049
Name:BIRD, RUSSELL ALLEN (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALLEN
Last Name:BIRD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-0464
Mailing Address - Country:US
Mailing Address - Phone:503-292-6773
Mailing Address - Fax:503-246-4206
Practice Address - Street 1:615 E 2ND ST
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-3100
Practice Address - Country:US
Practice Address - Phone:503-538-7717
Practice Address - Fax:503-538-7727
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD9083122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist