Provider Demographics
NPI:1619038361
Name:RUSSELL, DANA HOWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:HOWARD
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 1:6333 WILSHIRE BL
Mailing Address - Street 2:#503
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5721
Mailing Address - Country:US
Mailing Address - Phone:323-651-2171
Mailing Address - Fax:323-651-2171
Practice Address - Street 1:6333 WILSHIRE BL
Practice Address - Street 2:#503
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5721
Practice Address - Country:US
Practice Address - Phone:323-651-2171
Practice Address - Fax:323-651-2171
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA291791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA50041Medicare UPIN