Provider Demographics
NPI:1639197122
Name:RUSSO, EDWARD JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:
Last Name:RUSSO
Suffix:JR
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 1:5665 FIELDCREST DR
Mailing Address - Street 2:IC
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24590-3886
Mailing Address - Country:US
Mailing Address - Phone:434-286-3082
Mailing Address - Fax:
Practice Address - Street 1:5665 FIELDCREST DR
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24590-3886
Practice Address - Country:US
Practice Address - Phone:434-286-3082
Practice Address - Fax:434-286-3082
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401005184122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA008451192Medicaid