MEDICARE: DR. ROBERT ANTHONY 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
1	1223G0001X	General Practice Dentistry	20806	MA

General Provider Information

NPI Number	:	1891720066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ROBERT ANTHONY RUSSO D.M.D.

Provider Business Mailing Address
First Line	:	321 WASHINGTON ST
Second Line	:
City	:	GLOUCESTER
State	:	MA
Zip	:	01930-4837
Country	:	US
Telephone Number	:	978-281-1337
Fax Number	:	978-281-7573

Provider Business Practice Location Address
First Line	:	321 WASHINGTON ST
Second Line	:
City	:	GLOUCESTER
State	:	MA
Zip	:	01930-4837
Country	:	US
Telephone Number	:	978-281-1337
Fax Number	:	978-281-7573

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

Provider Enumeration Date	:	07/12/2006
Last Update Date	:	07/08/2007

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