Provider Demographics
NPI:1568598076
Name:RUSSO, PETER DAVID (DMD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:DAVID
Last Name:RUSSO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:53 MONTOWESE ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405
Mailing Address - Country:US
Mailing Address - Phone:203-483-1816
Mailing Address - Fax:203-483-1160
Practice Address - Street 1:53 MONTOWESE ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405
Practice Address - Country:US
Practice Address - Phone:203-483-1816
Practice Address - Fax:203-483-1160
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics