Provider Demographics
NPI:1548264328
Name:RUSSELL, CHARLES MARK (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MARK
Last Name:RUSSELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:HARROGATE
Mailing Address - State:TN
Mailing Address - Zip Code:37752-8208
Mailing Address - Country:US
Mailing Address - Phone:423-869-5485
Mailing Address - Fax:
Practice Address - Street 1:163 BEECH ST
Practice Address - Street 2:
Practice Address - City:HARROGATE
Practice Address - State:TN
Practice Address - Zip Code:37752-8208
Practice Address - Country:US
Practice Address - Phone:423-869-5485
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice