Healthcare Provider Details

I. General information

NPI: 1609797208
Provider Name (Legal Business Name): FIONA RUSS, RDHAP, PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 BULLPEN DR
FONTANA CA
92336-0141
US

IV. Provider business mailing address

5424 BULLPEN DR
FONTANA CA
92336-0141
US

V. Phone/Fax

Practice location:
  • Phone: 909-680-8835
  • Fax:
Mailing address:
  • Phone: 909-680-8835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: FIONA RUSS
Title or Position: PRESIDENT
Credential: RDHAP
Phone: 909-680-8835