MEDICARE: J CHRISTOPHER RUSSELL DDS AA PROFESSIONALCORPORATION

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	1223G0001X	General Practice Dentistry	37491	CA

General Provider Information

NPI Number	:	1801275318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J CHRISTOPHER RUSSELL DDS AA PROFESSIONALCORPORATION

Provider Business Mailing Address
First Line	:	3302 E BROADWAY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-5905
Country	:	US
Telephone Number	:	562-438-9486
Fax Number	:	562-438-0152

Provider Business Practice Location Address
First Line	:	3302 E BROADWAY
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-5905
Country	:	US
Telephone Number	:	562-438-9486
Fax Number	:	562-438-0152

Authorized Official
Title or Position	:	PRESIDENT AND CFO
Name	:	DR. J CHRISTOPHER RUSSELL
Credential	:	DDS
Telephone Number	:	562-438-9486

Provider Enumeration Date	:	05/29/2015
Last Update Date	:	05/29/2015

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