Provider Demographics
NPI:1245247964
Name:RUSS, RANDAL CHRISTIAN (DDS)
Entity type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:CHRISTIAN
Last Name:RUSS
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 1:3038 MEADE AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116
Mailing Address - Country:US
Mailing Address - Phone:619-280-4796
Mailing Address - Fax:619-280-3029
Practice Address - Street 1:3038 MEADE AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116
Practice Address - Country:US
Practice Address - Phone:619-280-4796
Practice Address - Fax:619-280-3029
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA392001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice