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General NPI Number Information
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NPI Number | 1780472308
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Entity Type | Individual
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Provider Name | JONATHAN P RUSSO DDS
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Gender | Male
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Dates
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Enumeration Date | 04/25/2025
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Last Update Date | 07/30/2025
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Provider Practice Location Address
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Address Line | 11110 FORT ST STE 106
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City | OMAHA
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State | NE
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Zip | 68164-2183
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Country | US
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Telephone | 402-492-8300
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Fax |
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Provider Business Mailing Address
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Address Line | 406 MAYMONT DR
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City | CRAMERTON
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State | NC
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Zip | 28032-1611
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Country | US
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Telephone | 704-840-6342
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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 | 8115
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License Number State | NE
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