Provider Demographics
NPI:1558485219
Name:RUSSELL A. BARRON, DDS, INC, PS
Entity Type:Organization
Organization Name:RUSSELL A. BARRON, DDS, INC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:BARRON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:360-629-2420
Mailing Address - Street 1:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-0819
Mailing Address - Country:US
Mailing Address - Phone:360-629-2420
Mailing Address - Fax:360-629-7211
Practice Address - Street 1:9619 271ST ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-0819
Practice Address - Country:US
Practice Address - Phone:360-629-2420
Practice Address - Fax:360-629-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2009-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00003899122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5320205Medicaid
WA0151502OtherL & I REGULAR PROVIDER #
WA8004236Medicaid
WA8924064OtherL & I CRIME VICTIMS PROV#