Active NPI
David Wayne Russell, DMD
- Dentist
- Las Cruces, NM
National Provider Identifier
1164915294
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- DD4897
- Practice address
- 4171 Northrise Drive
Las Cruces, NM 88011 - Phone
- (575) 521-9375
- Fax
- (575) 521-2637
- NPI assigned
- Jun 13, 2018
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DD4897 | NM | |
| Dentist | 122300000X | DD4897 | NM | Primary |
Addresses
Primary practice location
4171 Northrise Drive
Las Cruces, NM 88011
Mailing address
4171 Northrise Drive
Las Cruces, NM 88011
Phone (575) 521-9375
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 81627718 | Medicaid | NM |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DD4897 | NM | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1528848000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1723420800000",
"number": "1164915294",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4171 NORTHRISE DRIVE",
"city": "LAS CRUCES",
"state": "NM",
"postal_code": "88011",
"telephone_number": "575-521-9375",
"fax_number": "575-521-2637"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4171 NORTHRISE DRIVE",
"city": "LAS CRUCES",
"state": "NM",
"postal_code": "88011",
"telephone_number": "575-521-9375",
"fax_number": "575-521-2637"
}
],
"practiceLocations": [],
"basic": {
"last_name": "RUSSELL",
"first_name": "DAVID",
"middle_name": "WAYNE",
"credential": "DMD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2018-06-13",
"last_updated": "2024-08-12",
"certification_date": "2024-08-05",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NM",
"license": "DD4897",
"primary": false
},
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "NM",
"license": "DD4897",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "81627718",
"state": "NM"
}
],
"endpoints": [],
"other_names": []
}Other providers in Las Cruces, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 12, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.