Provider Demographics
NPI:1497313159
Name:RUSSO, MIA FRANCESCA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MIA
Middle Name:FRANCESCA
Last Name:RUSSO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 LAWNWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LONGMEADOW
Mailing Address - State:MA
Mailing Address - Zip Code:01106-3021
Mailing Address - Country:US
Mailing Address - Phone:413-335-2408
Mailing Address - Fax:
Practice Address - Street 1:110 LAWNWOOD AVE
Practice Address - Street 2:
Practice Address - City:LONGMEADOW
Practice Address - State:MA
Practice Address - Zip Code:01106-3021
Practice Address - Country:US
Practice Address - Phone:413-335-2408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-29
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
RIDEN03464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program