Provider Demographics
NPI:1760913156
Name:RUSSELL, DEBORAH KRYSTAL (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEBORAH
Middle Name:KRYSTAL
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 COMMERCIAL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78221-3117
Mailing Address - Country:US
Mailing Address - Phone:210-922-7000
Mailing Address - Fax:210-637-2484
Practice Address - Street 1:5542 WALZEM RD
Practice Address - Street 2:
Practice Address - City:WINDCREST
Practice Address - State:TX
Practice Address - Zip Code:78218-2103
Practice Address - Country:US
Practice Address - Phone:210-922-7000
Practice Address - Fax:210-637-2484
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-27
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32521122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist