MEDICARE: MR. JOHN DOUGLAS RUSSELL 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	122300000X	Dentist	20042	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902958077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN DOUGLAS RUSSELL DDS

Provider Business Mailing Address
First Line	:	4178 ASHBY COURT
Second Line	:
City	:	SHASTA LAKE CITY
State	:	CA
Zip	:	96019
Country	:	US
Telephone Number	:	530-275-2910
Fax Number	:	530-275-9335

Provider Business Practice Location Address
First Line	:	4178 ASHBY COURT
Second Line	:
City	:	SHASTA LAKE CITY
State	:	CA
Zip	:	96019
Country	:	US
Telephone Number	:	530-275-2910
Fax Number	:	530-275-9335

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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