Provider Demographics
NPI:1801275318
Name:J CHRISTOPHER RUSSELL DDS AA PROFESSIONALCORPORATION
Entity type:Organization
Organization Name:J CHRISTOPHER RUSSELL DDS AA PROFESSIONALCORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:J
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-438-9486
Mailing Address - Street 1:3302 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-5905
Mailing Address - Country:US
Mailing Address - Phone:562-438-9486
Mailing Address - Fax:562-438-0152
Practice Address - Street 1:3302 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5905
Practice Address - Country:US
Practice Address - Phone:562-438-9486
Practice Address - Fax:562-438-0152
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA374911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty