Basic Information
| Provider Information | |||||||||
| NPI: | 1063173466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUSSELL MODERN DENTISTRY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 920050 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753920050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1710 NE 122ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972301939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032952120 | ||||||||
| FaxNumber: | 5033053342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2022 | ||||||||
| LastUpdateDate: | 01/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | PANDHOH | ||||||||
| AuthorizedOfficialFirstName: | SUMEET | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5032952120 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 01/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.