Provider Demographics
NPI:1457844524
Name:JUSTIN M RUSSO DDS PLLC
Entity Type:Organization
Organization Name:JUSTIN M RUSSO DDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:919-890-5147
Mailing Address - Street 1:3811 ED DR STE 120
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2393
Mailing Address - Country:US
Mailing Address - Phone:919-890-5147
Mailing Address - Fax:
Practice Address - Street 1:13220 STRICKLAND RD STE 166
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-5213
Practice Address - Country:US
Practice Address - Phone:919-890-5147
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-12
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental