Healthcare Provider Details

I. General information

NPI: 1811041726
Provider Name (Legal Business Name): ANGELA MICHELLE ILLUZZI-RUSSO DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 PARK AVE
PORTLAND ME
04102-1000
US

IV. Provider business mailing address

10 LONE PINE LN
YARMOUTH ME
04096-6119
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1028
  • Fax:
Mailing address:
  • Phone: 917-502-0030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number052809
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22DI02347100
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN4836
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: