Provider Demographics
NPI:1770605412
Name:RUSSELL, CYNTHIA RAE (DDS)
Entity type:Individual
Prefix:DR
First Name:CYNTHIA
Middle Name:RAE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3294 ROYAL DR STE 103
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8503
Mailing Address - Country:US
Mailing Address - Phone:530-676-0127
Mailing Address - Fax:530-676-0129
Practice Address - Street 1:3294 ROYAL DR STE 103
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8503
Practice Address - Country:US
Practice Address - Phone:530-676-0127
Practice Address - Fax:530-676-0129
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice