Provider Demographics
NPI:1366568859
Name:RUSSELL, ELISA (DDS)
Entity type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ELISE
Other - Middle Name:
Other - Last Name:FEINSTEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1722 SAINT ANDREWS DR
Mailing Address - Street 2:
Mailing Address - City:MORAGA
Mailing Address - State:CA
Mailing Address - Zip Code:94556-1033
Mailing Address - Country:US
Mailing Address - Phone:925-818-0241
Mailing Address - Fax:
Practice Address - Street 1:1722 SAINT ANDREWS DR
Practice Address - Street 2:
Practice Address - City:MORAGA
Practice Address - State:CA
Practice Address - Zip Code:94556-1033
Practice Address - Country:US
Practice Address - Phone:925-818-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25276122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice