Provider Demographics
NPI:1013170968
Name:RUSSELL, RANDALL J (DDS)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:J
Last Name:RUSSELL
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 1:20971 E SMOKY HILL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5186
Mailing Address - Country:US
Mailing Address - Phone:720-870-1451
Mailing Address - Fax:720-870-1456
Practice Address - Street 1:20971 E SMOKY HILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-5186
Practice Address - Country:US
Practice Address - Phone:720-870-1451
Practice Address - Fax:720-870-1456
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CODEN.002019131223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program