Provider Demographics
NPI:1972811099
Name:RUSSELL, DEXTER
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:RUSSELL
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 1:3600 CERRILLOS RD
Mailing Address - Street 2:SUITE 407
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-424-8990
Mailing Address - Fax:
Practice Address - Street 1:3600 CERRILLOS RD
Practice Address - Street 2:SUITE 407
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-2612
Practice Address - Country:US
Practice Address - Phone:505-424-8990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0017172P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172P00000XOther Service ProvidersNaprapath