Healthcare Provider Details

I. General information

NPI: 1700870862
Provider Name (Legal Business Name): NATHAN GREGORY RUSSELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 94 BOX 168
APO AE
09824
TR

IV. Provider business mailing address

PSC 94 BOX 168
APO AE
09824
TR

V. Phone/Fax

Practice location:
  • Phone: 903223166104
  • Fax:
Mailing address:
  • Phone: 903223166104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE00009670
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: