Provider Demographics
NPI:1285836452
Name:RUSSO, THOMAS DAVID (DMD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:DAVID
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 SHORE RD STE 13
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-2828
Mailing Address - Country:US
Mailing Address - Phone:781-721-4700
Mailing Address - Fax:781-729-0798
Practice Address - Street 1:63 SHORE RD STE 13
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:MA
Practice Address - Zip Code:01890-2828
Practice Address - Country:US
Practice Address - Phone:781-721-4700
Practice Address - Fax:781-729-0798
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA661706OtherUNITED CONCORDIA
MARU10679OtherBLUE CROSS BLUE SHIELD
MA0263001Medicaid