Provider Demographics
NPI:1790415198
Name:RUSS, CHRISTIAN
Entity Type:Individual
Prefix:DR
First Name:CHRISTIAN
Middle Name:
Last Name:RUSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 SHENANDOAH RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-2633
Mailing Address - Country:US
Mailing Address - Phone:256-710-2128
Mailing Address - Fax:
Practice Address - Street 1:1906 BRUIN DR
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-6717
Practice Address - Country:US
Practice Address - Phone:256-764-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALD-0007048-C11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice