Provider Demographics
NPI:1922168343
Name:RUSSELL, BENJAMIN T (DMD)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:T
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:363 SE 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-4281
Mailing Address - Country:US
Mailing Address - Phone:503-756-9046
Mailing Address - Fax:
Practice Address - Street 1:742 NE DIVISION ST STE 102
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3979
Practice Address - Country:US
Practice Address - Phone:503-667-2442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD87291223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics