Provider Demographics
NPI:1205974177
Name:TOM, RUSSELL JUN SUNG (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JUN SUNG
Last Name:TOM
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 1:1481 S KING ST STE 504
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96814-2605
Mailing Address - Country:US
Mailing Address - Phone:808-944-1001
Mailing Address - Fax:
Practice Address - Street 1:1481 S KING ST STE 504
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96814-2605
Practice Address - Country:US
Practice Address - Phone:808-944-1001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH010068091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice