Samuel Yohannes Russom, DDS

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

License

DDS104651 Issued in CA

Practice address

2015 Birch Rd Ste 103
Chula Vista, CA 91915-2003

Phone

(619) 391-9287

NPI assigned

May 4, 2018

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• C Pham & S Mauseth Dental Corporation

  • Orthodontics and Dentofacial Orthopedics Dentistry
  • Chula Vista, CA
  • NPI 1548051287
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525392000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1640649600000",
    "number": "1144719196",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5311 OAK PARK DR",
            "city": "SAN DIEGO",
            "state": "CA",
            "postal_code": "921054959",
            "telephone_number": "619-263-0384"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2015 BIRCH RD STE 103",
            "city": "CHULA VISTA",
            "state": "CA",
            "postal_code": "919152003",
            "telephone_number": "619-391-9287"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "RUSSOM",
        "first_name": "SAMUEL",
        "middle_name": "YOHANNES",
        "name_prefix": "Dr.",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-05-04",
        "last_updated": "2021-12-28",
        "certification_date": "2021-12-28",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "CA",
            "license": "DDS104651",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Jennifer Rullan, MD
• Peter P Rullan, M.D.
• Andrew Rusnak, M.D.
• Dejahne Russell
• Patricia Ellen Russell
• Valentina Ruvalcaba, FNP
• Joseph Kevin Ryan, PA-C
• Megan Priscilla Ryan I
• Rygg and Singh Dental Corporation
• Emani Ajanae Ryles

• Pediatric Dentistry in Chula Vista, CA
• Providers in Chula Vista, CA by specialty
• Pediatric Dentistry in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 28, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.