Healthcare Provider Details

I. General information

NPI: 1902873276
Provider Name (Legal Business Name): CARL M. RUSSELL DMD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6488 HICKORY FLAT HWY
CANTON GA
30115-7235
US

IV. Provider business mailing address

6488 HICKORY FLAT HWY
CANTON GA
30115-7235
US

V. Phone/Fax

Practice location:
  • Phone: 770-720-8138
  • Fax: 770-720-7580
Mailing address:
  • Phone: 770-720-8138
  • Fax: 770-720-7580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number11115
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: