Provider Demographics
NPI:1366543258
Name:RUSSELL, KENNETH R (DDS)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KENNETH
Other - Middle Name:R
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS PA
Mailing Address - Street 1:1480 RYMCO DR STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-2944
Mailing Address - Country:US
Mailing Address - Phone:336-768-7940
Mailing Address - Fax:336-768-5985
Practice Address - Street 1:1480 RYMCO DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2944
Practice Address - Country:US
Practice Address - Phone:336-768-7940
Practice Address - Fax:336-768-5985
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8997537Medicaid