Provider Demographics
NPI:1093243917
Name:STEPHEN T. RUSO, D.D.S., M.S., P.L.L.C.
Entity Type:Organization
Organization Name:STEPHEN T. RUSO, D.D.S., M.S., P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-586-0560
Mailing Address - Street 1:3760 N WICKHAM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2326
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3760 N WICKHAM RD STE 1
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2326
Practice Address - Country:US
Practice Address - Phone:321-242-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty