Provider Demographics
NPI:1023154341
Name:SANDMAN, RUSSELL (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:
Last Name:SANDMAN
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 W 58TH ST APT 17D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-2509
Mailing Address - Country:US
Mailing Address - Phone:646-405-5555
Mailing Address - Fax:
Practice Address - Street 1:17331 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-5523
Practice Address - Country:US
Practice Address - Phone:718-291-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY05154111223X0400X
NJ22DI023092001223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02778912Medicaid