Provider Demographics
NPI:1538276969
Name:RUSSO, JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:RUSSO
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 1:1704 BAY RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-6810
Mailing Address - Country:US
Mailing Address - Phone:941-955-3100
Mailing Address - Fax:941-955-4769
Practice Address - Street 1:1704 BAY RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-6810
Practice Address - Country:US
Practice Address - Phone:941-955-3100
Practice Address - Fax:941-955-4769
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN127861223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics