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General NPI Number Information
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NPI Number | 1548347586
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Entity Type | Individual
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Provider Name | FRANK RUSSOMANNO JR. D.D.S.
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Gender | Male
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 8910 PENN AVE S
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City | BLOOMINGTON
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State | MN
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Zip | 55431-2025
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Country | US
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Telephone | 952-881-0504
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Fax | 952-884-0188
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Provider Business Mailing Address
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Address Line | 1423 KINGSWOOD PONDS RD
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City | EAGAN
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State | MN
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Zip | 55122-2878
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Country | US
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Telephone | 952-484-8703
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Fax | 952-884-0188
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D11333
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License Number State | MN
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