Healthcare Provider Details

I. General information

NPI: 1649963042
Provider Name (Legal Business Name): SMITH & RUSSELL DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2023
Last Update Date: 05/31/2023
Certification Date: 05/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 S HAWTHORNE RD
WINSTON SALEM NC
27103-4127
US

IV. Provider business mailing address

1601 S HAWTHORNE RD
WINSTON SALEM NC
27103-4127
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-9550
  • Fax: 336-765-9552
Mailing address:
  • Phone: 336-765-9550
  • Fax: 336-765-9552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: BRADLY KALB RUSSELL
Title or Position: ORAL SURGEON
Credential: DDS
Phone: 336-765-9550