Provider Demographics
NPI:1528196516
Name:RUSSELL, DAVID HENRY (DMD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:HENRY
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4414 KUKUI GROVE ST
Mailing Address - Street 2:SUITE #103
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-2016
Mailing Address - Country:US
Mailing Address - Phone:808-245-9339
Mailing Address - Fax:808-246-9242
Practice Address - Street 1:4414 KUKUI GROVE ST
Practice Address - Street 2:SUITE #103
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-2016
Practice Address - Country:US
Practice Address - Phone:808-245-9339
Practice Address - Fax:808-246-9242
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDT-18861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery