Provider Demographics
NPI:1144719196
Name:RUSSOM, SAMUEL YOHANNES (DDS)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:YOHANNES
Last Name:RUSSOM
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 1:5311 OAK PARK DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-4959
Mailing Address - Country:US
Mailing Address - Phone:619-263-0384
Mailing Address - Fax:
Practice Address - Street 1:2015 BIRCH RD STE 103
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-2003
Practice Address - Country:US
Practice Address - Phone:619-391-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1046511223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry