Provider Demographics
NPI:1699863191
Name:CLEVELAND, RUSSELL A (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:A
Last Name:CLEVELAND
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1670 HUGUENOT RD
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-2427
Mailing Address - Country:US
Mailing Address - Phone:804-794-4564
Mailing Address - Fax:804-794-9389
Practice Address - Street 1:1670 HUGUENOT RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-2427
Practice Address - Country:US
Practice Address - Phone:804-794-4564
Practice Address - Fax:804-794-9389
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010063051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice