=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619267903
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREGORY S RUSSELL, DMD, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2011
-----------------------------------------------------
Last Update Date | 12/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11200 RACETRACK RD STE 204
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-208-3333
-----------------------------------------------------
Fax | 410-208-3330
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11200 RACETRACK RD STE 204
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21811-3808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-208-3333
-----------------------------------------------------
Fax | 410-208-3330
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. GREGORY S RUSSELL
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 410-208-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 13423
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------