Healthcare Provider Details

I. General information

NPI: 1104846849
Provider Name (Legal Business Name): PETER ANTHONY RUSSO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18800 MAIN ST STE. 201
HUNTINGTON BEACH CA
92648-1707
US

IV. Provider business mailing address

18800 MAIN ST STE. 201
HUNTINGTON BEACH CA
92648-1707
US

V. Phone/Fax

Practice location:
  • Phone: 714-842-2515
  • Fax: 714-847-7075
Mailing address:
  • Phone: 714-842-2515
  • Fax: 714-847-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number41127
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: