Provider Demographics
NPI:1639377930
Name:CHURCH, GEORGE RUSSELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:RUSSELL
Last Name:CHURCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 NE 134TH ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98685-2719
Mailing Address - Country:US
Mailing Address - Phone:360-574-4007
Mailing Address - Fax:360-574-8516
Practice Address - Street 1:1412 NE 134TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98685-2719
Practice Address - Country:US
Practice Address - Phone:360-574-4007
Practice Address - Fax:360-574-8516
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6155122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist