Healthcare Provider Details

I. General information

NPI: 1700717980
Provider Name (Legal Business Name): CHRISTOPHER CLINTON RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 BYRAM PL STE C
BYRAM MS
39272-8739
US

IV. Provider business mailing address

127 LEWIS FARMS DR
MADISON MS
39110-1002
US

V. Phone/Fax

Practice location:
  • Phone: 601-373-1351
  • Fax:
Mailing address:
  • Phone: 601-954-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112651
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: