Provider Demographics
NPI:1811238264
Name:RANDALL J RUSSELL DDS PC
Entity type:Organization
Organization Name:RANDALL J RUSSELL DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:720-870-1451
Mailing Address - Street 1:20971 E SMOKY HILL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-5186
Mailing Address - Country:US
Mailing Address - Phone:720-870-1451
Mailing Address - Fax:720-870-1456
Practice Address - Street 1:20971 E SMOKY HILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-5186
Practice Address - Country:US
Practice Address - Phone:720-870-1451
Practice Address - Fax:720-870-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.00201913261QS0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery