Provider Demographics
NPI:1891063228
Name:RUSSELL G. TRIPP. D.D.S. LLC
Entity Type:Organization
Organization Name:RUSSELL G. TRIPP. D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:G
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-393-4600
Mailing Address - Street 1:28W530 BATAVIA RD
Mailing Address - Street 2:P.O. 291
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-3022
Mailing Address - Country:US
Mailing Address - Phone:630-393-4600
Mailing Address - Fax:630-393-4690
Practice Address - Street 1:28W530 BATAVIA RD
Practice Address - Street 2:P.O. 291
Practice Address - City:WARRENVILLE
Practice Address - State:IL
Practice Address - Zip Code:60555-3022
Practice Address - Country:US
Practice Address - Phone:630-393-4600
Practice Address - Fax:630-393-4690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190177491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty