Healthcare Provider Details

I. General information

NPI: 1205812765
Provider Name (Legal Business Name): NICOLAS HENRY RUSSO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PINCKNEY BLVD NAVAL HOSPITAL BEAUFORT
BEAUFORT SC
29902-6122
US

IV. Provider business mailing address

1 PINCKNEY BLVD NAVAL HOSPITAL BEAUFORT
BEAUFORT SC
29902-6122
US

V. Phone/Fax

Practice location:
  • Phone: 843-228-5577
  • Fax: 843-228-5196
Mailing address:
  • Phone: 843-228-5577
  • Fax: 843-228-5196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number039175
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: