Provider Demographics
NPI:1154476240
Name:BORTH, RUSSELL D
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:D
Last Name:BORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5756 S STAPLES ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-3782
Mailing Address - Country:US
Mailing Address - Phone:361-994-5414
Mailing Address - Fax:361-994-0022
Practice Address - Street 1:5756 S STAPLES ST
Practice Address - Street 2:SUITE B
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-3782
Practice Address - Country:US
Practice Address - Phone:361-994-5414
Practice Address - Fax:361-994-0022
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX142781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice