Provider Demographics
NPI:1841318565
Name:WANG, RUSSELL (DDS, MSD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:WANG
Suffix:
Gender:M
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10568 RAVENNA RD
Mailing Address - Street 2:STE 5
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-1654
Mailing Address - Country:US
Mailing Address - Phone:440-446-1819
Mailing Address - Fax:440-442-2316
Practice Address - Street 1:10568 RAVENNA RD
Practice Address - Street 2:STE 5
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-1654
Practice Address - Country:US
Practice Address - Phone:440-446-1819
Practice Address - Fax:440-442-2316
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0200601223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0285436Medicaid