Provider Demographics
NPI:1639191943
Name:RUSSELL, DTODD (DDS)
Entity Type:Individual
Prefix:
First Name:DTODD
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:DONALD
Other - Middle Name:TODD
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:9769 VALLEY VIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:MACEDONIA
Mailing Address - State:OH
Mailing Address - Zip Code:44056-1950
Mailing Address - Country:US
Mailing Address - Phone:330-468-6670
Mailing Address - Fax:
Practice Address - Street 1:9769 VALLEY VIEW ROAD
Practice Address - Street 2:
Practice Address - City:MACEDONIA
Practice Address - State:OH
Practice Address - Zip Code:44056-1950
Practice Address - Country:US
Practice Address - Phone:330-468-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH202121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2214786Medicaid
OH34-1946670OtherEIN