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NPI Code Detail

MEDICARE: DR. JEFFREY CARL RUSSO D.M.D.

MEDICARE: DR. JEFFREY CARL RUSSO D.M.D.
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
11223G0001XGeneral Practice Dentistry9049CT

General Provider Information

NPI Number : 1396862561
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JEFFREY CARL RUSSO D.M.D.
Provider Business Mailing Address
First Line : 148 NORTH RD
Second Line :
City : EAST WINDSOR
State : CT
Zip : 06088-9502
Country : US
Telephone Number : 860-627-5235
Fax Number :
Provider Business Practice Location Address
First Line : 148 NORTH RD
Second Line :
City : EAST WINDSOR
State : CT
Zip : 06088-9502
Country : US
Telephone Number : 860-627-5235
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/23/2007
Last Update Date : 07/08/2007

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