Provider Demographics
NPI:1730228040
Name:RUSSO, ANTHONY JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:JOSEPH
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 1:9 SANDBORN ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5410
Mailing Address - Country:US
Mailing Address - Phone:917-796-8612
Mailing Address - Fax:
Practice Address - Street 1:9 SANDBORN ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-5410
Practice Address - Country:US
Practice Address - Phone:917-796-8612
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice