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General NPI Number Information
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NPI Number | 1629173711
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Entity Type | Individual
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Provider Name | RUSSELL J COLLETT DDS
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Gender | Male
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Dates
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Enumeration Date | 09/13/2006
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Last Update Date | 03/17/2018
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Provider Practice Location Address
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Address Line | 1601 CONGRESS STREET
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City | PORTLAND
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State | ME
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Zip | 04102
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Country | US
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Telephone | 207-772-8055
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Fax | 207-772-8752
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Provider Business Mailing Address
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Address Line | 1601 CONGRESS STREET
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City | PORTLAND
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State | ME
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Zip | 04102
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Country | US
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Telephone | 207-772-8055
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Fax | 207-772-8752
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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 | 1223P0106X
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Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
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License Number | 3009
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 3009
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License Number State | ME
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Taxonomy #3
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Taxonomy Code | 1223X0008X
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Taxonomy Name | Oral and Maxillofacial Radiology Dentistry
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License Number | 3009
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License Number State | ME
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Taxonomy #4
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number | 3009
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License Number State | ME
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