Provider Demographics
NPI:1619032836
Name:RUSSELL, ZACHARY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:ZACHARY
Middle Name:D
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 HEARD AVE
Mailing Address - Street 2:BUILDING 556
Mailing Address - City:SCHOFIELD BARRACKS
Mailing Address - State:HI
Mailing Address - Zip Code:96857
Mailing Address - Country:US
Mailing Address - Phone:808-438-5555
Mailing Address - Fax:
Practice Address - Street 1:344 HEARD STREET
Practice Address - Street 2:BUILDING 556
Practice Address - City:SCHOFIELD BARRACKS
Practice Address - State:HI
Practice Address - Zip Code:96857
Practice Address - Country:US
Practice Address - Phone:808-438-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7062122300000X
HIDT-24051223G0001X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ156326OtherAHCCCS ID#