Provider Demographics
NPI:1124233309
Name:WOODSON, RUSSELL GLENN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GLENN
Last Name:WOODSON
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 1:155 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-2919
Mailing Address - Country:US
Mailing Address - Phone:415-929-6524
Mailing Address - Fax:415-929-6522
Practice Address - Street 1:155 5TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-2919
Practice Address - Country:US
Practice Address - Phone:415-929-6524
Practice Address - Fax:415-929-6522
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94-1738084OtherTAX ID#