Healthcare Provider Details

I. General information

NPI: 1265552160
Provider Name (Legal Business Name): JENNIFER ANN RUSSELL D.D.S., M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

5115 N PENNSYLVANIA ST
INDIANAPOLIS IN
46205-1038
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-7433
  • Fax:
Mailing address:
  • Phone: 317-726-0136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12010066A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: