Provider Demographics
NPI:1043877889
Name:RUSS, JOHN ALLEN (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ALLEN
Last Name:RUSS
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 1:6450 LA HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:BATCHELOR
Mailing Address - State:LA
Mailing Address - Zip Code:70715-3212
Mailing Address - Country:US
Mailing Address - Phone:225-492-3775
Mailing Address - Fax:
Practice Address - Street 1:6450 LA HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:BATCHELOR
Practice Address - State:LA
Practice Address - Zip Code:70715-3212
Practice Address - Country:US
Practice Address - Phone:225-637-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7028122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist