Provider Demographics
NPI:1346252616
Name:RUSSO, MICHAEL P (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:P
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 WALKER ST
Mailing Address - Street 2:
Mailing Address - City:NEWTONVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02460-1518
Mailing Address - Country:US
Mailing Address - Phone:617-964-1268
Mailing Address - Fax:
Practice Address - Street 1:67 HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-2734
Practice Address - Country:US
Practice Address - Phone:508-791-5529
Practice Address - Fax:508-791-4546
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD196441223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics