=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558485219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RUSSELL A. BARRON, DDS, INC, PS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2007
-----------------------------------------------------
Last Update Date | 11/19/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9619 271ST ST NW
-----------------------------------------------------
City | STANWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98292-0819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-629-2420
-----------------------------------------------------
Fax | 360-629-7211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 819
-----------------------------------------------------
City | STANWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98292-0819
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-629-2420
-----------------------------------------------------
Fax | 360-629-7211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RUSSELL ALLEN BARRON
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 360-629-2420
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DE00003899
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------