Healthcare Provider Details

I. General information

NPI: 1215010285
Provider Name (Legal Business Name): WILLARD DEAN RUSSELL JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 05/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 SUSHRUTA DRIVE
MARTINSBURG WV
25401
US

IV. Provider business mailing address

1007 SUSHRUTA DRIVE
MARTINSBURG WV
25401
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0991
  • Fax: 304-274-9546
Mailing address:
  • Phone: 304-263-0991
  • Fax: 304-274-9546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number2483
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6261
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDS030508L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: