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General NPI Number Information
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NPI Number | 1023408192
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Entity Type | Organization
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Legal Business Name | SPECIAL NEEDS DENTISTRY
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Dates
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Enumeration Date | 01/28/2015
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Last Update Date | 01/28/2015
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Provider Practice Location Address
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Address Line | 2420 QUAKER AVE SUITE 101
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City | LUBBOCK
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State | TX
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Zip | 79410-1817
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Country | US
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Telephone | 806-701-5066
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Fax |
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Provider Business Mailing Address
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Address Line | 16304 COUNTY ROAD 2040
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City | LUBBOCK
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State | TX
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Zip | 79423-4618
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Country | US
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Telephone | 806-368-2005
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Fax |
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Authorized Official
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Title or Position | OWNER/MANAGER
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Name | DR. RUSSELL WAYNE REDDELL
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Credential | DDS
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Telephone | 806-701-5066
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | 19405
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License Number State | TX
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