MEDICARE: DR. MARK ANTHONY LARUSSO D.D.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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	0401411249	VA
2	1223S0112X	Oral and Maxillofacial Surgery (Dentist)		IL

General Provider Information

NPI Number	:	1558358960
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK ANTHONY LARUSSO D.D.S.

Provider Business Mailing Address
First Line	:	2205 LEEWAY CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23455-1699
Country	:	US
Telephone Number	:	757-363-0321
Fax Number	:

Provider Business Practice Location Address
First Line	:	1647 TAUSSIG BOULEVARD
Second Line	:	NAVAL DENTAL CLINIC NORFOLK
City	:	NORFOLK
State	:	VA
Zip	:	23511-2896
Country	:	US
Telephone Number	:	757-953-8698
Fax Number	:

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	09/05/2007

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