Provider Demographics
NPI:1518670959
Name:DIRUSSO, DOMINIC JACOB (DDS)
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:JACOB
Last Name:DIRUSSO
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 1:1801 CREST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-1609
Mailing Address - Country:US
Mailing Address - Phone:972-567-4830
Mailing Address - Fax:
Practice Address - Street 1:1450 LONG PRAIRIE RD
Practice Address - Street 2:STE 160
Practice Address - City:FLOWER MOUND
Practice Address - State:TX
Practice Address - Zip Code:75028
Practice Address - Country:US
Practice Address - Phone:469-293-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-30
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX388831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice