Organization
SPECIAL NEEDS DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RUSSELL WAYNE REDDELL DDS (OWNER/MANAGER)
(806) 701-5066
Entity
Organization
Contact information
Practice address
2420 QUAKER AVE, SUITE 101, LUBBOCK, TX 79410-1817
(806) 701-5066
Mailing address
16304 COUNTY ROAD 2040, LUBBOCK, TX 79423-4618
(806) 368-2005
Taxonomy
Speciality
Code
Description
License number
State
1223D0001X
Public Health Dentistry
Primary
19405
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
180035102
—
TX
Enumeration date
01/28/2015
Last updated
01/28/2015
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