Provider Demographics
NPI:1902100316
Name:HUMBLE RICHMOND & RUSSELL ORAL & MAXILLOFACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:HUMBLE RICHMOND & RUSSELL ORAL & MAXILLOFACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-667-1431
Mailing Address - Street 1:1201 SE 223RD AVE
Mailing Address - Street 2:SUITE 180
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-2574
Mailing Address - Country:US
Mailing Address - Phone:503-667-1431
Mailing Address - Fax:503-492-0880
Practice Address - Street 1:1201 SE 223RD AVE
Practice Address - Street 2:SUITE 180
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-2574
Practice Address - Country:US
Practice Address - Phone:503-667-1431
Practice Address - Fax:503-492-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-28
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD66601223S0112X
ORD70531223S0112X
ORD92951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty