Provider Demographics
NPI:1669681292
Name:MARRIOTT, RUSSELL GEORGE (DMD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:GEORGE
Last Name:MARRIOTT
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 1:311 W THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-4149
Mailing Address - Country:US
Mailing Address - Phone:315-336-3210
Mailing Address - Fax:
Practice Address - Street 1:311 W THOMAS ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-4149
Practice Address - Country:US
Practice Address - Phone:315-336-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030387-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist