Provider Demographics
NPI:1023408192
Name:SPECIAL NEEDS DENTISTRY
Entity type:Organization
Organization Name:SPECIAL NEEDS DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:REDDELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:806-701-5066
Mailing Address - Street 1:16304 COUNTY ROAD 2040
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-4618
Mailing Address - Country:US
Mailing Address - Phone:806-368-2005
Mailing Address - Fax:
Practice Address - Street 1:2420 QUAKER AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1817
Practice Address - Country:US
Practice Address - Phone:806-701-5066
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX194051223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180035102Medicaid