Provider Demographics
NPI:1407474380
Name:RUSSELL PARK DENTAL CARE, LLC
Entity Type:Organization
Organization Name:RUSSELL PARK DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIGEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMCHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:301-284-8467
Mailing Address - Street 1:963 RUSSELL AVE STE A
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20879-3287
Mailing Address - Country:US
Mailing Address - Phone:301-284-8467
Mailing Address - Fax:
Practice Address - Street 1:963 RUSSELL AVE STE A
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20879-3287
Practice Address - Country:US
Practice Address - Phone:301-284-8467
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-08
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental