Provider Demographics
NPI:1952417479
Name:RUSSELL, DONALD M JR (DMD,PC)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:M
Last Name:RUSSELL
Suffix:JR
Gender:M
Credentials:DMD,PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2425 MEDICAL CENTER PKWY
Mailing Address - Street 2:
Mailing Address - City:SELMA
Mailing Address - State:AL
Mailing Address - Zip Code:36701-7756
Mailing Address - Country:US
Mailing Address - Phone:334-875-1330
Mailing Address - Fax:334-875-6284
Practice Address - Street 1:2425 MEDICAL CENTER PKWY
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:AL
Practice Address - Zip Code:36701-7756
Practice Address - Country:US
Practice Address - Phone:334-875-1330
Practice Address - Fax:334-875-6284
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL30631223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000095993Medicaid