Healthcare Provider Details

I. General information

NPI: 1801926548
Provider Name (Legal Business Name): RUSSELL MCCABE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3142 N NATIONAL RD
COLUMBUS IN
47201-3169
US

IV. Provider business mailing address

3142 N NATIONAL RD
COLUMBUS IN
47201-3169
US

V. Phone/Fax

Practice location:
  • Phone: 812-376-9425
  • Fax: 812-376-9428
Mailing address:
  • Phone: 812-376-9425
  • Fax: 812-376-9428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12009978
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: