Healthcare Provider Details

I. General information

NPI: 1003832684
Provider Name (Legal Business Name): DRS RUSSELL & NICHOLAS-HOLMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 12/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4714 EDMONDSON AVENUE
BALTIMORE MD
21229
US

IV. Provider business mailing address

4714 EDMONDSON AVENUE
BALTIMORE MD
21229
US

V. Phone/Fax

Practice location:
  • Phone: 410-566-4200
  • Fax: 410-566-1770
Mailing address:
  • Phone: 410-566-4200
  • Fax: 410-566-1770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MAY NICHOLAS-HOLMES
Title or Position: ORTHODONTIST
Credential:
Phone: 410-566-4200