Provider Demographics
NPI:1073917811
Name:JONES, M.A. RUSSELL JR (DDS)
Entity Type:Individual
Prefix:
First Name:M.A.
Middle Name:RUSSELL
Last Name:JONES
Suffix:JR
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 1:2594 SHAY CT
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2852
Mailing Address - Country:US
Mailing Address - Phone:707-725-5025
Mailing Address - Fax:707-725-7916
Practice Address - Street 1:2594 SHAY CT
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2852
Practice Address - Country:US
Practice Address - Phone:707-725-5025
Practice Address - Fax:707-725-7916
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26187122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA26187OtherCALIFORNIA DENTAL BOARD