Provider Demographics
NPI:1902031974
Name:SHANNON S. RUSSELL, DDS, INC.
Entity Type:Organization
Organization Name:SHANNON S. RUSSELL, DDS, INC.
Other - Org Name:1ST IMPRESSIONS DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:S
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-795-1535
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:CA
Mailing Address - Zip Code:95223-0029
Mailing Address - Country:US
Mailing Address - Phone:209-795-1535
Mailing Address - Fax:209-795-6733
Practice Address - Street 1:2720 HIGHWAY 4
Practice Address - Street 2:SUITE 3 & 4
Practice Address - City:ARNOLD
Practice Address - State:CA
Practice Address - Zip Code:95223
Practice Address - Country:US
Practice Address - Phone:209-795-1535
Practice Address - Fax:209-795-6733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty