Provider Demographics
NPI:1558764845
Name:STEPHENS, RUSSELL JOHN (DDS)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:JOHN
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:RUSSELL
Other - Middle Name:
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:424 N. WARREN AVE.
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156
Mailing Address - Country:US
Mailing Address - Phone:509-447-5960
Mailing Address - Fax:575-572-2259
Practice Address - Street 1:424 N. WARREN AVE.
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156
Practice Address - Country:US
Practice Address - Phone:509-447-5960
Practice Address - Fax:575-572-2259
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9051997-9921122300000X
WADE608510151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist