Provider Demographics
NPI:1356538151
Name:RUSSELL, ROBERT ROSS (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:ROSS
Last Name:RUSSELL
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Gender:M
Credentials:DMD, MS
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Mailing Address - Street 1:2402 LOGANVILLE HWY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:GRAYSON
Mailing Address - State:GA
Mailing Address - Zip Code:30017-1689
Mailing Address - Country:US
Mailing Address - Phone:770-236-9660
Mailing Address - Fax:770-236-9664
Practice Address - Street 1:2402 LOGANVILLE HWY
Practice Address - Street 2:SUITE 500
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-1689
Practice Address - Country:US
Practice Address - Phone:770-236-9660
Practice Address - Fax:770-236-9664
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GADN0127161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics