Healthcare Provider Details

I. General information

NPI: 1609211663
Provider Name (Legal Business Name): JOSEPH RUSSO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2013
Last Update Date: 10/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 WILLIAM ST
LYONS NY
14489-1544
US

IV. Provider business mailing address

47 WILLIAM ST
LYONS NY
14489-1544
US

V. Phone/Fax

Practice location:
  • Phone: 315-946-6511
  • Fax:
Mailing address:
  • Phone: 315-946-6511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number057342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: