Provider Demographics
NPI:1225558604
Name:RUSSO, JACQUELINE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11676 DUNES RD
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-5503
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11676 DUNES RD
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-5503
Practice Address - Country:US
Practice Address - Phone:561-212-9405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2017-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN129541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice