MEDICARE: DR. WYNN CHRISTOPHER RUSSO 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	1223G0001X	General Practice Dentistry	4223	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A-2040	OTHER	LA	BLUE CROSS

General Provider Information

NPI Number	:	1881656403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WYNN CHRISTOPHER RUSSO D.D.S.

Provider Business Mailing Address
First Line	:	2301 WILLIAMS BLVD
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70062-5721
Country	:	US
Telephone Number	:	504-887-7811
Fax Number	:	504-469-5181

Provider Business Practice Location Address
First Line	:	2301 WILLIAMS BLVD
Second Line	:
City	:	KENNER
State	:	LA
Zip	:	70062-5721
Country	:	US
Telephone Number	:	504-887-7811
Fax Number	:	504-469-5181

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

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	07/08/2007

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