Provider Demographics
NPI:1295291516
Name:NOLASCO, RUSSEL ROVIRA (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSEL
Middle Name:ROVIRA
Last Name:NOLASCO
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 1:41410 JUNIPER ST UNIT 3012
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-7516
Mailing Address - Country:US
Mailing Address - Phone:760-201-6519
Mailing Address - Fax:
Practice Address - Street 1:1042 N MOUNTAIN AVE STE A2
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3695
Practice Address - Country:US
Practice Address - Phone:909-579-0623
Practice Address - Fax:909-579-6483
Is Sole Proprietor?:No
Enumeration Date:2019-02-11
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1035371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice