Provider Demographics
NPI:1629611587
Name:DIRUSSO, VINCENT (DDS)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
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:972-567-4838
Mailing Address - Fax:
Practice Address - Street 1:1801 CREST VIEW DR
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-1609
Practice Address - Country:US
Practice Address - Phone:972-567-4838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX35631OtherDENTAL LICENSE