MEDICARE: DR. RUSSELL TOM MCDOUGAL MD

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	122300000X	Dentist	DN008520	GA

General Provider Information

NPI Number	:	1851498745
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RUSSELL TOM MCDOUGAL MD

Provider Business Mailing Address
First Line	:	2964 PEACHTREE ROAD
Second Line	:	SUITE 340
City	:	ATLANTA
State	:	GA
Zip	:	30305
Country	:	US
Telephone Number	:	404-239-9566
Fax Number	:	404-262-1744

Provider Business Practice Location Address
First Line	:	2964 PEACHTREE ROAD
Second Line	:	SUITE 340
City	:	ATLANTA
State	:	GA
Zip	:	30305
Country	:	US
Telephone Number	:	404-239-9566
Fax Number	:	404-262-1744

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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