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General NPI Number Information
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NPI Number | 1144719196
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Entity Type | Individual
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Provider Name | SAMUEL YOHANNES RUSSOM DDS
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Gender | Male
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Dates
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Enumeration Date | 05/04/2018
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Last Update Date | 12/28/2021
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Provider Practice Location Address
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Address Line | 2015 BIRCH RD STE 103
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City | CHULA VISTA
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State | CA
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Zip | 91915-2003
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Country | US
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Telephone | 619-391-9287
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Fax |
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Provider Business Mailing Address
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Address Line | 5311 OAK PARK DR
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City | SAN DIEGO
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State | CA
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Zip | 92105-4959
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Country | US
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Telephone | 619-263-0384
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DDS104651
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License Number State | CA
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