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General NPI Number Information
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NPI Number | 1811238264
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Entity Type | Organization
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Legal Business Name | RANDALL J RUSSELL DDS PC
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Dates
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Enumeration Date | 03/11/2013
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Last Update Date | 03/11/2013
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Provider Practice Location Address
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Address Line | 20971 E SMOKY HILL RD SUITE 201
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City | CENTENNIAL
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State | CO
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Zip | 80015-5186
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Country | US
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Telephone | 720-870-1451
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Fax | 720-870-1456
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Provider Business Mailing Address
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Address Line | 20971 E SMOKY HILL RD SUITE 201
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City | CENTENNIAL
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State | CO
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Zip | 80015-5186
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Country | US
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Telephone | 720-870-1451
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Fax | 720-870-1456
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Authorized Official
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Title or Position | OWNER
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Name | DR. RANDALL J RUSSELL
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Credential | DDS
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Telephone | 720-870-1451
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | DEN.00201913
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License Number State | CO
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