Provider Demographics
NPI:1902958077
Name:RUSSELL, JOHN DOUGLAS (DDS)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DOUGLAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4178 ASHBY COURT
Mailing Address - Street 2:
Mailing Address - City:SHASTA LAKE CITY
Mailing Address - State:CA
Mailing Address - Zip Code:96019
Mailing Address - Country:US
Mailing Address - Phone:530-275-2910
Mailing Address - Fax:530-275-9335
Practice Address - Street 1:4178 ASHBY COURT
Practice Address - Street 2:
Practice Address - City:SHASTA LAKE CITY
Practice Address - State:CA
Practice Address - Zip Code:96019
Practice Address - Country:US
Practice Address - Phone:530-275-2910
Practice Address - Fax:530-275-9335
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20042122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB2004201Medicaid