Healthcare Provider Details

I. General information

NPI: 1821231663
Provider Name (Legal Business Name): JOHN RUSSELL III D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2009
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 N BROOKMOORE DR
COLUMBUS MS
39705-2020
US

IV. Provider business mailing address

206 N BROOKMOORE DR
COLUMBUS MS
39705-2020
US

V. Phone/Fax

Practice location:
  • Phone: 662-328-1521
  • Fax: 662-328-1237
Mailing address:
  • Phone: 662-328-1521
  • Fax: 662-328-1237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2100-84
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: