Provider Demographics
NPI:1922029347
Name:RUSSELL, ROXANN (DDS)
Entity Type:Individual
Prefix:
First Name:ROXANN
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ROXANN
Other - Middle Name:RUSSELL
Other - Last Name:AVES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:16688 N. DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618
Mailing Address - Country:US
Mailing Address - Phone:813-374-9695
Mailing Address - Fax:813-333-7323
Practice Address - Street 1:16688 N. DALE MABRY HWY
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618
Practice Address - Country:US
Practice Address - Phone:813-374-9695
Practice Address - Fax:813-333-7323
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0161031223P0221X
TX17627122300000X
FLDN187941223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000084500Medicaid