Provider Demographics
NPI:1215010285
Name:RUSSELL, WILLARD DEAN JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLARD
Middle Name:DEAN
Last Name:RUSSELL
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 1:1007 SUSHRUTA DRIVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25401
Mailing Address - Country:US
Mailing Address - Phone:304-263-0991
Mailing Address - Fax:304-274-9546
Practice Address - Street 1:1007 SUSHRUTA DRIVE
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-263-0991
Practice Address - Fax:304-274-9546
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV24831223S0112X
MD62611223S0112X
PADS030508L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
066637OtherTRIGON
WV0136408000Medicaid
MDDF52OtherBCBS MD
MDLK72OtherDENTAL/MEDICAL
MDDF52OtherBCBS MD
WVRU0505372Medicare ID - Type Unspecified