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General NPI Number Information
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NPI Number | 1063553774
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Entity Type | Individual
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Provider Name | RICHARD G. RUSSO DMD
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Gender | Male
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Dates
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Enumeration Date | 02/08/2007
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Last Update Date | 03/07/2023
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Provider Practice Location Address
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Address Line | 832 W CENTRAL BLVD
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City | ORLANDO
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State | FL
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Zip | 32805-1809
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Country | US
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Telephone | 407-836-2616
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Fax |
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Provider Business Mailing Address
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Address Line | 2500 21ST ST NW APT 79
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City | WINTER HAVEN
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State | FL
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Zip | 33881-1275
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Country | US
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Telephone | 863-299-7748
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number | DN10829
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License Number State | FL
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