Provider Demographics
NPI:1144434036
Name:RUSS, SCOTT M (DDS)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:M
Last Name:RUSS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WEST JOHN STREET
Mailing Address - Street 2:
Mailing Address - City:HICKVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801
Mailing Address - Country:US
Mailing Address - Phone:516-681-2525
Mailing Address - Fax:516-681-3514
Practice Address - Street 1:82 WEST JOHN STREET
Practice Address - Street 2:
Practice Address - City:HICKVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801
Practice Address - Country:US
Practice Address - Phone:516-681-2525
Practice Address - Fax:516-681-3514
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04404311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice