# KENNETH R,. RUSSELL, D.D.S. PA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1902081094
- **Authorized official:** DR. KENNETH RAY RUSSELL D.D.S. (PRESIDENT)
- **Authorized official phone:** (336) 768-7940

## Contact information

- **Practice address:** 1480 RYMCO DR STE B, WINSTON SALEM, NC 27103-2944
- **Practice address phone:** (336) 768-7940
- **Practice address fax:** (336) 768-5985
- **Mailing address:** 1480 RYMCO DR STE B, WINSTON SALEM, NC 27103-2944
- **Mailing address phone:** (336) 768-7940
- **Mailing address fax:** (336) 768-5985

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 5843 | NC | Yes |

## Other

- **Enumeration date:** 01/08/2008
- **Last updated:** 01/08/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 890195B | — | NC |