Provider Demographics
NPI:1053485672
Name:RUSSO, PETER J (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:J
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 WOODBURY AVE
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02061
Mailing Address - Country:US
Mailing Address - Phone:617-699-4862
Mailing Address - Fax:508-832-5374
Practice Address - Street 1:567 SOUTHBRIDGE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:MA
Practice Address - Zip Code:01520
Practice Address - Country:US
Practice Address - Phone:508-832-3317
Practice Address - Fax:508-832-5374
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19637122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist