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General NPI Number Information
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NPI Number | 1699918201
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Entity Type | Organization
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Legal Business Name | JOHN RUSSELL, III, D.M.D.
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Dates
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Enumeration Date | 04/13/2009
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Last Update Date | 04/13/2009
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Provider Practice Location Address
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Address Line | 400 2ND AVE N
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City | AMORY
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State | MS
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Zip | 38821-3513
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Country | US
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Telephone | 662-256-3260
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Fax |
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Provider Business Mailing Address
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Address Line | 206 N BROOKMOORE DR
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City | COLUMBUS
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State | MS
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Zip | 39705-2020
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Country | US
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Telephone | 662-328-1521
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Fax | 662-328-1237
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JOHN RUSSELL III
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Credential | D.M.D.
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Telephone | 662-328-1521
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | OR15888
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License Number State | MS
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