Provider Demographics
NPI:1922166164
Name:RUSSELL, TAMARA DUNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:DUNN
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 FELTON PL # B
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-2152
Mailing Address - Country:US
Mailing Address - Phone:770-382-3536
Mailing Address - Fax:770-382-1915
Practice Address - Street 1:16 FELTON PL # B
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-2152
Practice Address - Country:US
Practice Address - Phone:770-382-3536
Practice Address - Fax:770-382-1915
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0110411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100299OtherAVESIS MEDICAID
GA9181142OtherDORAL MEDICAID
GA00945128AMedicaid