Healthcare Provider Details

I. General information

NPI: 1922089986
Provider Name (Legal Business Name): RUSSELL EVANS SPEER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

564 W 25TH ST
MERCED CA
95340-2828
US

IV. Provider business mailing address

564 W 25TH ST
MERCED CA
95340-2828
US

V. Phone/Fax

Practice location:
  • Phone: 209-722-6257
  • Fax:
Mailing address:
  • Phone: 209-722-6257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number26788
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: