Provider Demographics
NPI:1932490307
Name:RUSSELL, BRADLY KALB (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLY
Middle Name:KALB
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4127
Mailing Address - Country:US
Mailing Address - Phone:336-765-9550
Mailing Address - Fax:336-765-9552
Practice Address - Street 1:1601 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4127
Practice Address - Country:US
Practice Address - Phone:336-765-9550
Practice Address - Fax:336-765-9552
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.02399111223S0112X
NC115361223S0112X
OH30-0239911223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program