Provider Demographics
NPI:1770705311
Name:RUSSELL, SHANNON (DDS)
Entity type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:
Last Name:RUSSELL
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:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:CA
Mailing Address - Zip Code:95223-0029
Mailing Address - Country:US
Mailing Address - Phone:209-795-1535
Mailing Address - Fax:209-795-6733
Practice Address - Street 1:2720 HIGHWAY 4
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:CA
Practice Address - Zip Code:95223
Practice Address - Country:US
Practice Address - Phone:209-795-1535
Practice Address - Fax:209-795-6733
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice