Provider Demographics
NPI:1619267903
Name:GREGORY S RUSSELL, DMD, P.A.
Entity Type:Organization
Organization Name:GREGORY S RUSSELL, DMD, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:410-208-3333
Mailing Address - Street 1:11200 RACETRACK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-3808
Mailing Address - Country:US
Mailing Address - Phone:410-208-3333
Mailing Address - Fax:410-208-3330
Practice Address - Street 1:11200 RACETRACK RD STE 204
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-3808
Practice Address - Country:US
Practice Address - Phone:410-208-3333
Practice Address - Fax:410-208-3330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-08
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD134231223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD13423OtherDENTAL LIC#
MD1760452890OtherPERSONAL NPI
MD64080OtherSTATE CDS LIC#
MD13423OtherDENTAL LIC#