Provider Demographics
NPI:1962462507
Name:VALENTINE, RUSSELL S (DDS)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:S
Last Name:VALENTINE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220S 38TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98418-7807
Mailing Address - Country:US
Mailing Address - Phone:253-475-4631
Mailing Address - Fax:253-475-2635
Practice Address - Street 1:220 S 38TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7847
Practice Address - Country:US
Practice Address - Phone:253-475-4631
Practice Address - Fax:253-475-2635
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA72901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA846654OtherUNITED CONCORDIA