Provider Demographics
NPI:1548290091
Name:RUSSELL, GREG THOMAS (DMD)
Entity type:Individual
Prefix:DR
First Name:GREG
Middle Name:THOMAS
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3184
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-3184
Mailing Address - Country:US
Mailing Address - Phone:904-797-7901
Mailing Address - Fax:904-797-3423
Practice Address - Street 1:2520 US HIGHWAY 1 S
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-6194
Practice Address - Country:US
Practice Address - Phone:904-797-7901
Practice Address - Fax:904-797-3423
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 89741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice