Provider Demographics
NPI:1831108463
Name:RUSSELL, TIMOTHY ELMER III
Entity Type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:ELMER
Last Name:RUSSELL
Suffix:III
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 1:2616 SHERWOOD HALL LANE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22306
Mailing Address - Country:US
Mailing Address - Phone:703-360-1776
Mailing Address - Fax:703-360-1776
Practice Address - Street 1:2616 SHERWOOD HALL LANE
Practice Address - Street 2:SUITE 405
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22306
Practice Address - Country:US
Practice Address - Phone:703-360-1776
Practice Address - Fax:703-360-1776
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04010032821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice