Provider Demographics
NPI:1609211663
Name:RUSSO, JOSEPH (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:RUSSO
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 1:47 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:LYONS
Mailing Address - State:NY
Mailing Address - Zip Code:14489-1544
Mailing Address - Country:US
Mailing Address - Phone:315-946-6511
Mailing Address - Fax:
Practice Address - Street 1:47 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:NY
Practice Address - Zip Code:14489-1544
Practice Address - Country:US
Practice Address - Phone:315-946-6511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-05
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY057342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist