MEDICARE: DR. JENNIFER ANN RUSSELL D.D.S., M.S.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	12010066A	IN

General Provider Information

NPI Number	:	1265552160
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JENNIFER ANN RUSSELL D.D.S., M.S.D.

Provider Business Mailing Address
First Line	:	5115 N PENNSYLVANIA ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1038
Country	:	US
Telephone Number	:	317-726-0136
Fax Number	:

Provider Business Practice Location Address
First Line	:	13752 LAKERIDGE DR
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46037-7608
Country	:	US
Telephone Number	:	317-576-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/02/2007
Last Update Date	:	07/08/2007

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