Provider Demographics
NPI:1902081094
Name:KENNETH R,. RUSSELL, D.D.S. PA
Entity Type:Organization
Organization Name:KENNETH R,. RUSSELL, D.D.S. PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:336-768-7940
Mailing Address - Street 1:1480 RYMCO DR STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2944
Mailing Address - Country:US
Mailing Address - Phone:336-768-7940
Mailing Address - Fax:336-768-5985
Practice Address - Street 1:1480 RYMCO DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2944
Practice Address - Country:US
Practice Address - Phone:336-768-7940
Practice Address - Fax:336-768-5985
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890195BMedicaid