Provider Demographics
NPI:1275022782
Name:RUSSELL, MALLORY K (DDS)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:K
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:K
Other - Last Name:COCHRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6400 CANOGA AVENUE WARNER CENTER DENTAL GROUP
Mailing Address - Street 2:#180
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367
Mailing Address - Country:US
Mailing Address - Phone:818-887-2880
Mailing Address - Fax:
Practice Address - Street 1:6400 CANOGA AVENUE WARNER CENTER DENTAL GROUP
Practice Address - Street 2:#180
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367
Practice Address - Country:US
Practice Address - Phone:818-887-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-09
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA1040771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty