MEDICARE: DR. STEPHEN RUSO D.D.S., M.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DN 19633	FL

General Provider Information

NPI Number	:	1285913723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN RUSO D.D.S., M.S.

Provider Business Mailing Address
First Line	:	3412 WESTFIELD DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-7736
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 W REYNOLDS ST
Second Line	:
City	:	PLANT CITY
State	:	FL
Zip	:	33563-4700
Country	:	US
Telephone Number	:	813-567-7001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/15/2011
Last Update Date	:	11/22/2012

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