Provider Demographics
NPI:1346704889
Name:RUSSELL, JAMIE ELLEN (RDH)
Entity Type:Individual
Prefix:MS
First Name:JAMIE
Middle Name:ELLEN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 A VINTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLTON
Mailing Address - State:MA
Mailing Address - Zip Code:01507-6544
Mailing Address - Country:US
Mailing Address - Phone:508-688-9890
Mailing Address - Fax:
Practice Address - Street 1:26 QUEEN ST STE 13
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2478
Practice Address - Country:US
Practice Address - Phone:508-963-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-29
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA13270124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist