Provider Demographics
NPI:1487734067
Name:RUSSELL, ANDREA W (DMD)
Entity type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:W
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8014 CUMMING HWY
Mailing Address - Street 2:SUITE 401
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-9339
Mailing Address - Country:US
Mailing Address - Phone:770-345-2010
Mailing Address - Fax:770-345-0571
Practice Address - Street 1:8014 CUMMING HWY
Practice Address - Street 2:SUITE 401
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-9339
Practice Address - Country:US
Practice Address - Phone:770-345-2010
Practice Address - Fax:770-345-0571
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GADN012175122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist