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General NPI Number Information
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NPI Number | 1639197122
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Entity Type | Individual
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Provider Name | EDWARD RUSSO JR. DDS
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Gender | Male
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Dates
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Enumeration Date | 07/17/2006
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Last Update Date | 02/08/2017
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Provider Practice Location Address
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Address Line | 5665 FIELDCREST DR
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City | SCOTTSVILLE
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State | VA
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Zip | 24590-3886
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Country | US
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Telephone | 434-286-3082
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Fax | 434-286-3082
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Provider Business Mailing Address
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Address Line | 5665 FIELDCREST DR IC
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City | SCOTTSVILLE
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State | VA
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Zip | 24590-3886
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Country | US
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Telephone | 434-286-3082
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 0401005184
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License Number State | VA
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