Provider Demographics
NPI:1427660703
Name:RED HILLS ORAL AND FACIAL SURGERY, PA
Entity type:Organization
Organization Name:RED HILLS ORAL AND FACIAL SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTHER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MD
Authorized Official - Phone:352-284-0232
Mailing Address - Street 1:2648 CENTENNIAL PL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0572
Mailing Address - Country:US
Mailing Address - Phone:850-523-3000
Mailing Address - Fax:850-523-0831
Practice Address - Street 1:2648 CENTENNIAL PL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-0572
Practice Address - Country:US
Practice Address - Phone:850-523-3000
Practice Address - Fax:850-523-0831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty