Healthcare Provider Details

I. General information

NPI: 1942297643
Provider Name (Legal Business Name): RUSSELL DENTAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 PEACHTREE PLZ
BROWNSVILLE TN
38012-2500
US

IV. Provider business mailing address

130 PEACHTREE PLZ
BROWNSVILLE TN
38012-2500
US

V. Phone/Fax

Practice location:
  • Phone: 731-772-2107
  • Fax:
Mailing address:
  • Phone: 731-772-2107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7764
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6983
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2338
License Number StateTN

VIII. Authorized Official

Name: DR. THOMAS DUCKWORTH RUSSELL III
Title or Position: CORPORATION PRESIDENT, DENTIST
Credential: D.D.S.
Phone: 731-772-2107