Individual
KEITH EDMUND RUSSELL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
495 WOODFORD ST, PORTLAND, ME 04103-2438
(207) 772-6966
(207) 761-0756
Mailing address
495 WOODFORD ST, PORTLAND, ME 04103-2438
(207) 772-6966
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
3414
ME
1223G0001X
General Practice Dentistry
Primary
3414
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
043377401
INDIVIDUAL TAX ID #
ME
05
—
264030099
—
ME
Enumeration date
12/04/2006
Last updated
03/20/2023
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