Provider Demographics
NPI:1659449940
Name:RUSSELL FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:RUSSELL FAMILY DENTISTRY LLC
Other - Org Name:REGAN & RUSSELL LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:EDMUND
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-772-6966
Mailing Address - Street 1:495 WOODFORD STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-772-6966
Mailing Address - Fax:207-761-0756
Practice Address - Street 1:495 WOODFORD STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-772-6966
Practice Address - Fax:207-761-0756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-03
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME154630000OtherMAINE CARE