Individual
DR. BRADLY KALB RUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1601 S HAWTHORNE RD, WINSTON SALEM, NC 27103-4127
(336) 765-9550
(336) 765-9552
Mailing address
1601 S HAWTHORNE RD, WINSTON SALEM, NC 27103-4127
(336) 765-9550
(336) 765-9552
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
11536
NC
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
30-023991
OH
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
30.0239911
OH
390200000X
Student in an Organized Health Care Education/Training Program
—
—
Other
Enumeration date
04/20/2011
Last updated
10/06/2021
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