Provider Demographics
NPI:1831710771
Name:RUSSELL, MARK WILLIAM (DMD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7351
Mailing Address - Country:US
Mailing Address - Phone:910-638-8413
Mailing Address - Fax:
Practice Address - Street 1:2815 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:TRENT WOODS
Practice Address - State:NC
Practice Address - Zip Code:28562-7351
Practice Address - Country:US
Practice Address - Phone:252-633-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-01
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC118361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice