Provider Demographics
NPI:1538300165
Name:MORITA, RUSSELL K (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:K
Last Name:MORITA
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 1:516 W BADILLO ST
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91722-3762
Mailing Address - Country:US
Mailing Address - Phone:626-966-8673
Mailing Address - Fax:
Practice Address - Street 1:516 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-3762
Practice Address - Country:US
Practice Address - Phone:626-966-8673
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28048122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist