MEDICARE: DR. ANTHONY RUSSELL IMMEDIATA DMD, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	5022	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609809292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANTHONY RUSSELL IMMEDIATA DMD, PA

Provider Business Mailing Address
First Line	:	7101 CREEDMOOR RD
Second Line	:	SUITE 109
City	:	RALEIGH
State	:	NC
Zip	:	27613-1682
Country	:	US
Telephone Number	:	919-846-5500
Fax Number	:

Provider Business Practice Location Address
First Line	:	7101 CREEDMOOR RD
Second Line	:	SUITE 109
City	:	RALEIGH
State	:	NC
Zip	:	27613-1682
Country	:	US
Telephone Number	:	919-846-5500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2006
Last Update Date	:	07/08/2007

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