Provider Demographics
NPI:1538372388
Name:RUSSELL, STACEY L (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
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 1:132 JEFFERSON HTS
Mailing Address - Street 2:
Mailing Address - City:CATSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12414-1215
Mailing Address - Country:US
Mailing Address - Phone:518-943-0920
Mailing Address - Fax:518-943-0921
Practice Address - Street 1:132 JEFFERSON HTS
Practice Address - Street 2:
Practice Address - City:CATSKILL
Practice Address - State:NY
Practice Address - Zip Code:12414-1215
Practice Address - Country:US
Practice Address - Phone:518-943-0920
Practice Address - Fax:518-943-0921
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0510181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice