Healthcare Provider Details

I. General information

NPI: 1023408192
Provider Name (Legal Business Name): SPECIAL NEEDS DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2015
Last Update Date: 01/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 QUAKER AVE SUITE 101
LUBBOCK TX
79410-1817
US

IV. Provider business mailing address

16304 COUNTY ROAD 2040
LUBBOCK TX
79423-4618
US

V. Phone/Fax

Practice location:
  • Phone: 806-701-5066
  • Fax:
Mailing address:
  • Phone: 806-368-2005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number19405
License Number StateTX

VIII. Authorized Official

Name: DR. RUSSELL WAYNE REDDELL
Title or Position: OWNER/MANAGER
Credential: DDS
Phone: 806-701-5066