Provider Demographics
NPI:1689763187
Name:HARRELL, CLINTON RUSSELL (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:RUSSELL
Last Name:HARRELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98663-2257
Mailing Address - Country:US
Mailing Address - Phone:360-695-6844
Mailing Address - Fax:360-735-1567
Practice Address - Street 1:3606 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-2257
Practice Address - Country:US
Practice Address - Phone:360-695-6844
Practice Address - Fax:360-735-1567
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE88981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice