Provider Demographics
NPI:1538316526
Name:RUSSELL, SALLY W (RDH)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:W
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 1:725 OLD POST RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6684
Mailing Address - Country:US
Mailing Address - Phone:203-256-3020
Mailing Address - Fax:203-254-8850
Practice Address - Street 1:725 OLD POST RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6684
Practice Address - Country:US
Practice Address - Phone:203-256-3020
Practice Address - Fax:203-254-8850
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002137124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist