Healthcare Provider Details

I. General information

NPI: 1245341981
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY & ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 PROSPECT ST SUITE 1A
MIDLAND PARK NJ
07432-1606
US

IV. Provider business mailing address

6 PROSPECT ST SUITE 1A
MIDLAND PARK NJ
07432-1606
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-5555
  • Fax: 201-445-5057
Mailing address:
  • Phone: 201-445-5555
  • Fax: 201-445-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CARMINE CARLO RUSSO
Title or Position: GENERAL PARTNER
Credential: DMD, MS
Phone: 201-445-5555