Healthcare Provider Details

I. General information

NPI: 1619267903
Provider Name (Legal Business Name): GREGORY S RUSSELL, DMD, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 12/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 RACETRACK RD STE 204
BERLIN MD
21811-3808
US

IV. Provider business mailing address

11200 RACETRACK RD STE 204
BERLIN MD
21811-3808
US

V. Phone/Fax

Practice location:
  • Phone: 410-208-3333
  • Fax: 410-208-3330
Mailing address:
  • Phone: 410-208-3333
  • Fax: 410-208-3330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number13423
License Number StateMD

VIII. Authorized Official

Name: DR. GREGORY S RUSSELL
Title or Position: PRESIDENT
Credential: DMD
Phone: 410-208-3333