=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154560589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOMAS D. RUSSO, D.M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2009
-----------------------------------------------------
Last Update Date | 06/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 SHORE RD STE 13
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01890-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-721-4700
-----------------------------------------------------
Fax | 781-729-0798
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 63 SHORE RD STE 13
-----------------------------------------------------
City | WINCHESTER
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01890-2828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 781-721-4700
-----------------------------------------------------
Fax | 781-729-0798
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | THOMAS D RUSSO
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 781-721-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 15641
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------