Provider Demographics
NPI:1851498745
Name:MCDOUGAL, RUSSELL TOM (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:TOM
Last Name:MCDOUGAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2964 PEACHTREE ROAD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-239-9566
Mailing Address - Fax:404-262-1744
Practice Address - Street 1:2964 PEACHTREE ROAD
Practice Address - Street 2:SUITE 340
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:404-239-9566
Practice Address - Fax:404-262-1744
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN008520122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist