MEDICARE: RUSSELL ARTHUR VINCENT DDS

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	1223G0001X	General Practice Dentistry	DE00006784	WA
2	122300000X	Dentist	DE00006784	WA

General Provider Information

NPI Number	:	1518950211
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL ARTHUR VINCENT DDS

Provider Business Mailing Address
First Line	:	955 POWELL AVE SW
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98057-2908
Country	:	US
Telephone Number	:	425-277-1311
Fax Number	:

Provider Business Practice Location Address
First Line	:	403 E MEEKER ST
Second Line	:	STE 100
City	:	KENT
State	:	WA
Zip	:	98030-5904
Country	:	US
Telephone Number	:	253-796-4071
Fax Number	:	253-796-4076

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

Provider Enumeration Date	:	08/26/2005
Last Update Date	:	12/18/2020

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