Healthcare Provider Details

I. General information

NPI: 1609809292
Provider Name (Legal Business Name): ANTHONY RUSSELL IMMEDIATA DMD, PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 CREEDMOOR RD SUITE 109
RALEIGH NC
27613-1682
US

IV. Provider business mailing address

7101 CREEDMOOR RD SUITE 109
RALEIGH NC
27613-1682
US

V. Phone/Fax

Practice location:
  • Phone: 919-846-5500
  • Fax:
Mailing address:
  • Phone: 919-846-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5022
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: