Healthcare Provider Details

I. General information

NPI: 1376071365
Provider Name (Legal Business Name): ROBERT JAMES RUSSELL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 09/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6865 OAK CREEK DR
COLUMBUS OH
43229-1501
US

IV. Provider business mailing address

14 LUCILLE DR
SYOSSET NY
11791-3724
US

V. Phone/Fax

Practice location:
  • Phone: 641-808-8478
  • Fax:
Mailing address:
  • Phone: 516-244-2552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.025583
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: