Provider Demographics
NPI:1619141611
Name:RUSSO, CHRISTOPHER JOHN (DDS)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:JOHN
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 1:903 PONDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-4214
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1979 LONGWOOD LAKE MARY RD
Practice Address - Street 2:SUITE 1013
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4670
Practice Address - Country:US
Practice Address - Phone:407-320-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN15234122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist