Provider Demographics
NPI:1326738915
Name:RUSSELL, EMILY CRAYTON
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:CRAYTON
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 SOM CENTER RD STE B14
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2911
Mailing Address - Country:US
Mailing Address - Phone:440-248-9005
Mailing Address - Fax:
Practice Address - Street 1:6200 SOM CENTER RD STE B14
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2911
Practice Address - Country:US
Practice Address - Phone:440-248-9005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0271271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice