Provider Demographics
NPI:1558358960
Name:LARUSSO, MARK ANTHONY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ANTHONY
Last Name:LARUSSO
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 1:2205 LEEWAY CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1699
Mailing Address - Country:US
Mailing Address - Phone:757-363-0321
Mailing Address - Fax:
Practice Address - Street 1:1647 TAUSSIG BOULEVARD
Practice Address - Street 2:NAVAL DENTAL CLINIC NORFOLK
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23511-2896
Practice Address - Country:US
Practice Address - Phone:757-953-8698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014112491223S0112X
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery