1861605487 NPI number — DR. ROBERT RUEL RUSSELL DMD, MD

Table of content: DR. ROBERT RUEL RUSSELL DMD, MD (NPI 1861605487)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861605487 NPI number — DR. ROBERT RUEL RUSSELL DMD, MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RUSSELL
Provider First Name:
ROBERT
Provider Middle Name:
RUEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD, MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861605487
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 180
Provider Business Mailing Address City Name:
OREGON CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97045-1867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-650-6116
Provider Business Mailing Address Fax Number:
503-650-6198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
911 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 180
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1867
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-650-6116
Provider Business Practice Location Address Fax Number:
503-650-6198
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  21510 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 204E00000X , with the licence number: MD28928 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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