Provider Demographics
NPI:1144208505
Name:PARAVECCHIO, RUSSELL F (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:F
Last Name:PARAVECCHIO
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 1:705 136TH PL NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-4712
Mailing Address - Country:US
Mailing Address - Phone:425-644-6096
Mailing Address - Fax:425-644-8115
Practice Address - Street 1:705 136TH PL NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98005-4722
Practice Address - Country:US
Practice Address - Phone:425-644-6096
Practice Address - Fax:425-644-8115
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-05
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000046611223P0221X, 1223D0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0004XDental ProvidersDentistDentist Anesthesiologist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5047774Medicaid
WAAB37798Medicare ID - Type Unspecified
WA5047774Medicaid