Provider Demographics
NPI:1598866154
Name:BIBB, RUSSELL EUGENE JR (DMD)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:EUGENE
Last Name:BIBB
Suffix:JR
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:PO BOX 960
Mailing Address - Street 2:
Mailing Address - City:ESTACADA
Mailing Address - State:OR
Mailing Address - Zip Code:97023
Mailing Address - Country:US
Mailing Address - Phone:503-630-4211
Mailing Address - Fax:503-630-4260
Practice Address - Street 1:103 SW HWY 224
Practice Address - Street 2:STE A
Practice Address - City:ESTACADA
Practice Address - State:OR
Practice Address - Zip Code:97023
Practice Address - Country:US
Practice Address - Phone:503-630-4211
Practice Address - Fax:503-630-4260
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAD61541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22197-8Medicaid
ORAD6154OtherOREGON DENTAL
AB2655819OtherFEDERAL DEA