Provider Demographics
NPI:1578610903
Name:JACINTO, RUSSEL R (DMD)
Entity Type:Individual
Prefix:
First Name:RUSSEL
Middle Name:R
Last Name:JACINTO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 N GLENDALE AVE
Mailing Address - Street 2:#100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4903
Mailing Address - Country:US
Mailing Address - Phone:818-240-6705
Mailing Address - Fax:818-240-3758
Practice Address - Street 1:144 N GLENDALE AVE
Practice Address - Street 2:#100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4903
Practice Address - Country:US
Practice Address - Phone:818-240-6705
Practice Address - Fax:818-240-3758
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37841122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578610903OtherMEDI CAL