Provider Demographics
NPI:1568684140
Name:YELLOW SPRINGS DENTAL CARE JOHN T RUSSELL DDS INC.
Entity Type:Organization
Organization Name:YELLOW SPRINGS DENTAL CARE JOHN T RUSSELL DDS INC.
Other - Org Name:YELLOW SPRINGS DENTAL CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:937-767-7731
Mailing Address - Street 1:1030 XENIA AVE
Mailing Address - Street 2:PO BOX 839
Mailing Address - City:YELLOW SPRINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45387-1632
Mailing Address - Country:US
Mailing Address - Phone:937-767-7731
Mailing Address - Fax:
Practice Address - Street 1:1030 XENIA AVE
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-1632
Practice Address - Country:US
Practice Address - Phone:937-767-7731
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.013562261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN16600OtherSTATE
OH1679511489OtherNPI
OH30.013562OtherSTATE