Provider Demographics
NPI:1124387683
Name:TAYLOR, RUSSELL DEMETRIUS III (DDS)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:DEMETRIUS
Last Name:TAYLOR
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 UPTOWN BLVD STE 3100
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-3535
Mailing Address - Country:US
Mailing Address - Phone:910-551-8020
Mailing Address - Fax:
Practice Address - Street 1:1515 N TOWN EAST BLVD STE 215
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4144
Practice Address - Country:US
Practice Address - Phone:972-686-1955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT812366099211223G0001X
TX357031223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty