Healthcare Provider Details

I. General information

NPI: 1639191943
Provider Name (Legal Business Name): DTODD RUSSELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DONALD TODD RUSSELL DDS

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9769 VALLEY VIEW ROAD
MACEDONIA OH
44056-1950
US

IV. Provider business mailing address

9769 VALLEY VIEW ROAD
MACEDONIA OH
44056-1950
US

V. Phone/Fax

Practice location:
  • Phone: 330-468-6670
  • Fax:
Mailing address:
  • Phone: 330-468-6670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number20212
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: