Provider Demographics
NPI:1790076198
Name:RUSSELL, LAUREN KENNEDY (DDS)
Entity Type:Individual
Prefix:DR
First Name:LAUREN
Middle Name:KENNEDY
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5741 OAK CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45424-4089
Mailing Address - Country:US
Mailing Address - Phone:919-593-4268
Mailing Address - Fax:
Practice Address - Street 1:2200 OLYMPIC ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2858
Practice Address - Country:US
Practice Address - Phone:937-390-0493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0238021223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071244Medicaid