Provider Demographics
NPI:1629173711
Name:COLLETT, RUSSELL J (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:J
Last Name:COLLETT
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 1:1601 CONGRESS STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102
Mailing Address - Country:US
Mailing Address - Phone:207-772-8055
Mailing Address - Fax:207-772-8752
Practice Address - Street 1:1601 CONGRESS STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102
Practice Address - Country:US
Practice Address - Phone:207-772-8055
Practice Address - Fax:207-772-8752
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30091223P0106X, 1223S0112X, 1223X0008X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME221210000Medicaid
T95336Medicare UPIN
MEMM305801Medicare PIN
MEMM3058Medicare ID - Type Unspecified
MEMM305802Medicare PIN