Provider Demographics
NPI:1386659951
Name:LITIN, RUSSELL B (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:B
Last Name:LITIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:888 WORCESTER ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:WELLESLEY
Mailing Address - State:MA
Mailing Address - Zip Code:02482-3744
Mailing Address - Country:US
Mailing Address - Phone:617-964-6681
Mailing Address - Fax:339-686-2561
Practice Address - Street 1:888 WORCESTER ST
Practice Address - Street 2:SUITE 130
Practice Address - City:WELLESLEY
Practice Address - State:MA
Practice Address - Zip Code:02482-3744
Practice Address - Country:US
Practice Address - Phone:617-964-6681
Practice Address - Fax:339-686-2561
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0272906Medicaid
MAX06251OtherBLUE CROSS BLUE SHIELD