Provider Demographics
NPI:1881060838
Name:RUSSEL R JACINTO DMD INC
Entity type:Organization
Organization Name:RUSSEL R JACINTO DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:JACINTO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-240-6705
Mailing Address - Street 1:144 N GLENDALE AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4903
Mailing Address - Country:US
Mailing Address - Phone:818-240-6705
Mailing Address - Fax:818-240-3758
Practice Address - Street 1:144 N GLENDALE AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4903
Practice Address - Country:US
Practice Address - Phone:818-240-6705
Practice Address - Fax:818-240-3758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-13
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA378411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty