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General NPI Number Information
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NPI Number | 1720583222
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Entity Type | Individual
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Provider Name | ALEJANDRO JAVIER WISCOVITCH RUSSO DMD
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Gender | Male
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Dates
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Enumeration Date | 03/27/2018
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Last Update Date | 07/16/2021
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Provider Practice Location Address
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Address Line | ASPEN DENTAL 1159 ULSTER AVE
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City | KINGSTON
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State | NY
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Zip | 12401
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Country | US
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Telephone | 845-336-0500
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Fax |
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Provider Business Mailing Address
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Address Line | 7 VINEYARD LN APT 111
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City | NEWBURGH
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State | NY
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Zip | 12550-7066
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Country | US
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Telephone | 787-643-5041
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 061693
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License Number State | NY
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