Provider Demographics
NPI:1811068620
Name:ANDERSON, RUSSELL G JR (DMD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:G
Last Name:ANDERSON
Suffix:JR
Gender:M
Credentials:DMD
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Mailing Address - Street 1:1415 WOOTEN LAKE RD NW
Mailing Address - Street 2:SUITE 300
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1350
Mailing Address - Country:US
Mailing Address - Phone:770-419-2535
Mailing Address - Fax:770-419-0030
Practice Address - Street 1:1415 WOOTEN LAKE RD NW
Practice Address - Street 2:SUITE 300
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1350
Practice Address - Country:US
Practice Address - Phone:770-419-2535
Practice Address - Fax:770-419-0030
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA0114571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice