Healthcare Provider Details

I. General information

NPI: 1760913156
Provider Name (Legal Business Name): DEBORAH KRYSTAL RUSSELL D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2017
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5542 WALZEM RD
WINDCREST TX
78218-2103
US

IV. Provider business mailing address

3750 COMMERCIAL AVE
SAN ANTONIO TX
78221-3117
US

V. Phone/Fax

Practice location:
  • Phone: 210-922-7000
  • Fax: 210-637-2484
Mailing address:
  • Phone: 210-922-7000
  • Fax: 210-637-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32521
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: