Provider Demographics
NPI:1811023963
Name:RUSSELL, JOHN THOMAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:RUSSELL
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 1:1116 WEST ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3608
Mailing Address - Country:US
Mailing Address - Phone:410-268-7737
Mailing Address - Fax:410-268-4873
Practice Address - Street 1:1116 WEST ST
Practice Address - Street 2:SUITE B
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3608
Practice Address - Country:US
Practice Address - Phone:410-268-7737
Practice Address - Fax:410-268-4873
Is Sole Proprietor?:No
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD45111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice