Healthcare Provider Details

I. General information

NPI: 1881247039
Provider Name (Legal Business Name): BENJAMIN T RUSSELL DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 NE DIVISION ST STE 102
GRESHAM OR
97030-3979
US

IV. Provider business mailing address

742 NE DIVISION ST STE 102
GRESHAM OR
97030-3979
US

V. Phone/Fax

Practice location:
  • Phone: 503-667-2442
  • Fax:
Mailing address:
  • Phone: 503-667-2442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. BENJAMIN RUSSELL
Title or Position: OWNER
Credential:
Phone: 503-667-2442