Provider Demographics
NPI:1881247039
Name:BENJAMIN T RUSSELL DMD LLC
Entity type:Organization
Organization Name:BENJAMIN T RUSSELL DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-667-2442
Mailing Address - Street 1:742 NE DIVISION ST STE 102
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-3979
Mailing Address - Country:US
Mailing Address - Phone:503-667-2442
Mailing Address - Fax:
Practice Address - Street 1:742 NE DIVISION ST STE 102
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3979
Practice Address - Country:US
Practice Address - Phone:503-667-2442
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental