Provider Demographics
NPI:1306035423
Name:CHARLES D. RUSSO, DMD,PA
Entity Type:Organization
Organization Name:CHARLES D. RUSSO, DMD,PA
Other - Org Name:CORAL SPRINGS ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:954-752-1045
Mailing Address - Street 1:2801 N UNIVERSITY DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-5057
Mailing Address - Country:US
Mailing Address - Phone:954-752-1045
Mailing Address - Fax:954-344-9651
Practice Address - Street 1:2801 N UNIVERSITY DR
Practice Address - Street 2:SUITE 102
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065-5057
Practice Address - Country:US
Practice Address - Phone:954-752-1045
Practice Address - Fax:954-344-9651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00083381223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL39318Medicare PIN