Provider Demographics
NPI:1316379217
Name:RUSSO, HENRY RALPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:RALPH
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 WESTCHESTER AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2535
Mailing Address - Country:US
Mailing Address - Phone:914-251-0117
Mailing Address - Fax:914-251-0254
Practice Address - Street 1:3010 WESTCHESTER AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2535
Practice Address - Country:US
Practice Address - Phone:914-251-0117
Practice Address - Fax:914-251-0254
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-01
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042549122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist