Provider Demographics
NPI:1689109340
Name:JASON E. RUSSELL, DDS PA
Entity Type:Organization
Organization Name:JASON E. RUSSELL, DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACCOUNT MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:R
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-884-2212
Mailing Address - Street 1:510 FERNDALE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-4761
Mailing Address - Country:US
Mailing Address - Phone:336-884-2212
Mailing Address - Fax:336-884-4477
Practice Address - Street 1:510 FERNDALE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4761
Practice Address - Country:US
Practice Address - Phone:336-884-2212
Practice Address - Fax:336-884-4477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9115122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty