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General NPI Number Information
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NPI Number | 1407862675
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Entity Type | Individual
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Provider Name | JULIE MICAL RUSSO D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 07/31/2006
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Last Update Date | 11/14/2018
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Provider Practice Location Address
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Address Line | 3165 CITRUS TOWER BLVD
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City | CLERMONT
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State | FL
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Zip | 34711-6883
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Country | US
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Telephone | 352-241-6333
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Fax | 352-241-0706
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Provider Business Mailing Address
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Address Line | 3165 CITRUS TOWER BLVD
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City | CLERMONT
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State | FL
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Zip | 34711-6883
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Country | US
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Telephone | 352-241-6333
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Fax | 352-241-0706
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | DN16399
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License Number State | FL
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