Healthcare Provider Details

I. General information

NPI: 1326309253
Provider Name (Legal Business Name): RUSSELL TRITAPOE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HC 63 BOX 3560
ROMNEY WV
26757-9722
US

IV. Provider business mailing address

PO BOX 738
FORT ASHBY WV
26719-0738
US

V. Phone/Fax

Practice location:
  • Phone: 304-822-4447
  • Fax: 304-822-7943
Mailing address:
  • Phone: 304-298-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3997
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: