Healthcare Provider Details

I. General information

NPI: 1972811099
Provider Name (Legal Business Name): DEXTER RUSSELL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 CERRILLOS RD SUITE 407
SANTA FE NM
87507-2612
US

IV. Provider business mailing address

3600 CERRILLOS RD SUITE 407
SANTA FE NM
87507
US

V. Phone/Fax

Practice location:
  • Phone: 505-424-8990
  • Fax:
Mailing address:
  • Phone: 505-424-8990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172P00000X
TaxonomyNaprapath
License Number0017
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: